Cycle 1
Health 2025-12-04 · Fire 2025-12-04
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cumming, GA
Cumming Operating Company LLC
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2775 Castleberry Road, Cumming, GA
(770) 781-2300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Michael Feist
Operator or chain grouping
Approved since
1993-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 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
0.87
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.16
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.75
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,929
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.59
Baseline 20.52% · Performance 20.70% · Measure score 1.59 · Achievement 1.59 · Improvement 0
Healthcare-associated infections
1.27
Baseline 6.59% · Performance 7.46% · Measure score 1.27 · Achievement 1.27 · Improvement 0
Total nurse turnover
1.79
Baseline 30.36% · Performance 56.38% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Adjusted total nurse staffing
1.21
Baseline 4.16 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.16% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 335 · Observed rate 12.24% · Lower 95% interval 10.01% |
| Discharge to community | 70.39% |
50.57%
19.8 pts better
|
Better than the National Rate · Eligible stays 332 · Observed rate 61.14% · Lower 95% interval 65.19% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 88.68% |
95.27%
6.6 pts worse
|
Numerator 376 · Denominator 424 |
| Falls with major injury | 0.47% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 424 |
| Discharge self-care score | 67.8% |
53.69%
14.1 pts better
|
Numerator 120 · Denominator 177 |
| Discharge mobility score | 59.89% |
50.94%
9 pts better
|
Numerator 106 · Denominator 177 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 8 · Denominator 424 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 317 · Observed rate 7.57% · Lower 95% interval 5.43% |
| Staff COVID-19 vaccination coverage | 1.82% |
8.2%
6.4 pts worse
|
Numerator 3 · Denominator 165 |
| Staff flu vaccination coverage | 18.07% |
42%
23.9 pts worse
|
Numerator 30 · Denominator 166 |
| Discharge function score | 67.23% |
56.45%
10.8 pts better
|
Numerator 119 · Denominator 177 |
| Transfer of health information to provider | 97.98% |
95.95%
2 pts better
|
Numerator 291 · Denominator 297 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 105 · Denominator 110 |
| Resident COVID-19 vaccinations up to date | 30.74% |
25.2%
5.5 pts better
|
Numerator 75 · Denominator 244 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.0
1.1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 8.0% · Q4 8.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.3% |
9.6%
13.7 pts worse
|
11.4%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 27.6% · Q3 41.7% · 4Q avg 23.3% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.6% |
20.7%
14.9 pts worse
|
19.6%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 33.3% · Q3 35.0% · 4Q avg 35.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
21.4%
7.9 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 13.6% · 4Q avg 13.5% · 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 | 8.9% |
17.9%
9 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.4% |
16.2%
13.8 pts better
|
14.9%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · 4Q avg 2.4% · 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 | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 24.2% |
16.1%
8.1 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 16.9% · Q3 22.4% · Q4 46.2% · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
6.2%
3.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.9% · Q3 3.7% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
80.4%
17.7 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 96.8% · Q3 98.6% · Q4 99.7% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
12.2%
2.1 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.7% · Expected 10.7% · 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 3.2% · Q2 2.8% · Q3 2.2% · Q4 2.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
78.2%
17.9 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
24.2%
0.8 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 23.5% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-09
F · Potential for more than minimal harm
2024-08-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-29
F · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-29
D · Potential for more than minimal harm
2022-10-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-04
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 2025-12-22
F · Potential for more than minimal harm
2024-08-15
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 2024-09-29
E · Potential for more than minimal harm
2024-08-15
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 2024-09-29
E · Potential for more than minimal harm
2024-08-15
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 2024-09-29
D · Potential for more than minimal harm
2024-08-15
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 2024-09-29
D · Potential for more than minimal harm
2024-08-15
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 2024-09-29
F · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
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 2022-12-11
Penalties and ownership
What sits behind the stars
Ownership
Feist, Michael
5% Or Greater Direct Ownership Interest · Individual
Feist, Michael
Corporate Officer · Individual
Feist, Michael
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Chestnut Ridge Nsg & Rehab Ctr
Cumming, GA
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
#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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