Cycle 1
Health 2025-02-02 · Fire 2025-02-02
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cumming, GA
Chestnut Ridge Nsg & Rehab Ctr
1-star overall rating with 1-star inspections with $15,593 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
125 Samaritan Drive, Cumming, GA
(770) 889-0120
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
150
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cypress Skilled Nursing
Operator or chain grouping
Approved since
1989-07-01
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
0.38
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,486
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.19% · Performance 22.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.86
Baseline 6.24% · Performance 7.28% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Total nurse turnover
0
Baseline 60.00% · Performance 74.54% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.34 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 13.86% · Lower 95% interval 8.47% |
| Discharge to community | 54.3% |
50.57%
3.7 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 43.05% · Lower 95% interval 45.32% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.74% |
95.27%
0.5 pts better
|
Numerator 90 · Denominator 94 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 94 |
| Discharge self-care score | 39.34% |
53.69%
14.3 pts worse
|
Numerator 24 · Denominator 61 |
| Discharge mobility score | 44.26% |
50.94%
6.7 pts worse
|
Numerator 27 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 5.32% |
2.29%
3 pts worse
|
Numerator 5 · Denominator 94 · Adjusted rate 4.56% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 9.64% · Lower 95% interval 4.68% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 69 |
| Discharge function score | 47.54% |
56.45%
8.9 pts worse
|
Numerator 29 · Denominator 61 |
| Transfer of health information to provider | 92.59% |
95.95%
3.4 pts worse
|
Numerator 25 · Denominator 27 |
| Transfer of health information to patient | 65.63% |
96.28%
30.7 pts worse
|
Numerator 21 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 7 · Denominator 49 |
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 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
91.2%
2.4 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 96.6% · Q3 91.3% · Q4 95.1% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.6% |
95.0%
4.4 pts worse
|
95.5%
4.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 2.6% · Q4 4.1% · 4Q avg 3.8% · 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 | 5.2% |
5.9%
0.7 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.7% · Q3 8.0% · Q4 1.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
20.7%
0.6 pts better
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 20.4% · Q3 21.5% · Q4 21.0% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
21.4%
0.8 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 25.0% · Q3 21.2% · Q4 16.1% · 4Q avg 20.6% · 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 | 26.0% |
17.9%
8.1 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 36.6% · Q3 27.7% · Q4 21.0% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
16.2%
5.4 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 25.8% · Q3 20.5% · Q4 18.9% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.5%
0.8 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.9% · Q3 1.8% · Q4 1.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
16.1%
8.9 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 25.6% · Q3 24.0% · Q4 22.7% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.2%
1.5 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.4% · Q3 5.2% · Q4 5.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
80.4%
9 pts worse
|
81.7%
10.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 76.0% · Q3 55.3% · Q4 70.7% · 4Q avg 71.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
12.2%
3.5 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
2.2%
0.8 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.8% · Q3 3.4% · Q4 1.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.5% |
78.2%
9.7 pts worse
|
79.7%
11.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
24.2%
1.8 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 23.2% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
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 2025-03-19
D · Potential for more than minimal harm
2025-02-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-19
D · Potential for more than minimal harm
2023-08-24
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-02
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 2025-03-19
F · Potential for more than minimal harm
2025-02-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-02-02
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 2025-03-19
D · Potential for more than minimal harm
2025-02-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-02
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 2025-03-19
D · Potential for more than minimal harm
2025-02-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-19
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-22
E · Potential for more than minimal harm
2023-08-24
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 2023-10-05
E · Potential for more than minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-05
L · Immediate jeopardy
2023-05-03
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 2023-06-09
L · Immediate jeopardy
2023-05-03
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 2023-06-09
L · Immediate jeopardy
2023-05-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-09
L · Immediate jeopardy
2023-05-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-03
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 2023-06-09
D · Potential for more than minimal harm
2023-05-03
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-06-09
E · Potential for more than minimal harm
2021-11-04
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 2021-12-19
D · Potential for more than minimal harm
2021-11-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-12-19
D · Potential for more than minimal harm
2021-11-04
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 2021-12-19
D · Potential for more than minimal harm
2021-11-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-12-19
Penalties and ownership
What sits behind the stars
$4,429
2023-05-03
Fine
Fine · fine $4,429
Fine
$11,164
2023-05-03
Fine
Fine · fine $11,164
Fine
Ownership
Cypress Operating LLC
5% Or Greater Indirect Ownership Interest · Organization
Cypress Skilled Nursing LLC
5% Or Greater Direct Ownership Interest · Organization
Bender, Sara
Operational/Managerial Control · Individual
Cypress Skilled Nursing LLC
Operational/Managerial Control · Organization
Macatula, Maria
Operational/Managerial Control · Individual
Moss, Brent
Operational/Managerial Control · Individual
Nardiello, Elizabeth
Operational/Managerial Control · Individual
Nordholm, Katherine
Operational/Managerial Control · Individual
Ovits, Isaac
Operational/Managerial Control · Individual
Patterson, Dianne
Operational/Managerial Control · Individual
Patterson, Timothy
Operational/Managerial Control · Individual
Phillip, Karen
Operational/Managerial Control · Individual
Shaikh, Faizan
Operational/Managerial Control · Individual
Whipple, Michael
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cumming Operating Company LLC
Cumming, GA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - Lanier
Buford, GA
3-star overall rating with 3-star inspections with $3,728 in total fines with 8 recent health deficiencies
#3
D Scott Hudgens Center For Skilled Nursing, The
Suwanee, GA
4-star overall rating with 4-star inspections with $4,017 in total fines with 2 recent health deficiencies
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