Cycle 1
Health 2025-04-10 · Fire 2025-04-10
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Carrollton, GA
BHM Pine Knoll OpCo Inc
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
156 Pine Knoll Drive, Carrollton, GA
(770) 832-8243
Overall
3 / 5
CMS overall stars
Health inspections
4 / 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
122
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cypress Skilled Nursing
Operator or chain grouping
Approved since
1989-10-01
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
0.11
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
0.89
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
1.57
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.67
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
1.43
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.10
CMS adjusted RN staffing hours
Adjusted total hours
1.42
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,376
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9932
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.12
Baseline 19.72% · Performance 18.13% · Measure score 7.12 · Achievement 7.12 · Improvement 5.40
Healthcare-associated infections
7.52
Baseline 7.36% · Performance 5.59% · Measure score 7.52 · Achievement 7.52 · Improvement 6.99
Total nurse turnover
0.68
Baseline 55.45% · Performance 60.91% · Measure score 0.68 · Achievement 0.68 · Improvement 0
Adjusted total nurse staffing
0.78
Baseline 2.87 hours · Performance 3.24 hours · Measure score 0.78 · Achievement 0.56 · Improvement 0.78
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.01% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 6.06% · Lower 95% interval 6.37% |
| Discharge to community | 44.86% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 34.62% · Lower 95% interval 34.22% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.84% |
95.27%
3.6 pts better
|
Numerator 85 · Denominator 86 |
| Falls with major injury | 2.33% |
0.77%
1.6 pts worse
|
Numerator 2 · Denominator 86 |
| Discharge self-care score | 41.27% |
53.69%
12.4 pts worse
|
Numerator 26 · Denominator 63 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 18 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 2 · Denominator 86 · Adjusted rate 1.89% |
| Healthcare-associated infections requiring hospitalization | 5.59% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 2.78% · Lower 95% interval 3.31% |
| Staff COVID-19 vaccination coverage | 9.52% |
8.2%
1.3 pts better
|
Numerator 12 · Denominator 126 |
| Staff flu vaccination coverage | 20.75% |
42%
21.2 pts worse
|
Numerator 44 · Denominator 212 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 21 · Denominator 63 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 19.61% |
25.2%
5.6 pts worse
|
Numerator 10 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · 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 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
91.2%
6 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.9% · Q3 97.0% · Q4 96.9% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
95.0%
2.8 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.2%
0.4 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.2% · Q3 2.0% · Q4 2.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
9.6%
1.5 pts better
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.6% · Q3 9.6% · Q4 8.8% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.9%
1.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 2.5% · Q3 4.5% · Q4 2.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.3% |
20.7%
7.6 pts worse
|
19.6%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 28.2% · Q3 25.8% · Q4 28.9% · 4Q avg 28.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
21.4%
11.5 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 10.5% · Q3 10.4% · Q4 9.6% · 4Q avg 9.9% · 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 | 20.2% |
17.9%
2.3 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 23.7% · Q3 18.2% · Q4 20.1% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
16.2%
2.9 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 20.3% · Q3 8.1% · Q4 13.4% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.1%
0.5 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.5%
1.3 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.5% · Q3 5.3% · Q4 3.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.9% |
16.1%
7.2 pts better
|
19.8%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.0% · Q3 6.7% · Q4 8.1% · 4Q avg 8.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.2%
2.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.4% · Q3 4.6% · Q4 6.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.6% |
80.4%
4.2 pts better
|
81.7%
2.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 82.9% · Q3 83.5% · Q4 90.2% · 4Q avg 84.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.1% |
12.2%
10.9 pts worse
|
12.0%
11.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 22.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.2%
0.5 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.7% · Q3 1.7% · Q4 2.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.5% |
78.2%
3.7 pts worse
|
79.7%
5.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
24.2%
2.8 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 22.8% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-02 · Fire 2023-02-02
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-09-30 · Fire 2021-09-30
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
F · Potential for more than minimal harm
2023-02-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-02-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-17
F · Potential for more than minimal harm
2021-09-30
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-09-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-09-30
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2021-11-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
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 2025-05-23
D · Potential for more than minimal harm
2023-10-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-02-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-02
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 2023-03-17
D · Potential for more than minimal harm
2023-02-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-17
F · Potential for more than minimal harm
2021-09-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-09-30
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 2021-11-19
D · Potential for more than minimal harm
2021-09-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-09-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-11-19
Penalties and ownership
What sits behind the stars
$5,244
2023-06-12
Fine
Fine · fine $5,244
Fine
Ownership
Cypress Operating LLC
5% Or Greater Indirect Ownership Interest · Organization
Cypress Skilled Nursing LLC
5% Or Greater Direct Ownership Interest · Organization
Murphy, Melissa
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
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
#2
BHM Carrollton OpCo Inc
Carrollton, GA
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
#3
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
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