Decatur, GA

Decatur Center For Nursing And Healing LLC

2-star overall rating with 2-star inspections with 9 recent health deficiencies

2722 North Decatur Road, Decatur, GA

(404) 296-5440

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

140

Certified beds

Average residents

120

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Empire Care Centers

Operator or chain grouping

Approved since

1977-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

18 facilities

Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars

Changed ownership

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

0.71

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

1.76

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.25

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.48

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.92

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.64

CMS adjusted RN staffing hours

Adjusted total hours

2.93

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

38%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,597

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

48.82

Composite VBP score used to determine payment impact.

Payment multiplier

1.0026

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.56

Baseline 23.24% · Performance 19.48% · Measure score 5.56 · Achievement 4.21 · Improvement 5.56

Healthcare-associated infections

6.38

Baseline 6.89% · Performance 5.93% · Measure score 6.38 · Achievement 6.38 · Improvement 4.59

Total nurse turnover

7.59

Baseline 30.30% · Performance 32.65% · Measure score 7.59 · Achievement 7.59 · Improvement 0

Adjusted total nurse staffing

Baseline 3.48 hours · Performance 2.9 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.37%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 204 · Observed rate 8.33% · Lower 95% interval 6.75%
Discharge to community	59.34%	50.57% 8.8 pts better	Better than the National Rate · Eligible stays 242 · Observed rate 48.35% · Lower 95% interval 50.92%
Medicare spending per beneficiary	1.18	1.02 0.2 pts worse
Drug regimen review with follow-up	95.86%	95.27% 0.6 pts better	Numerator 139 · Denominator 145
Falls with major injury	0.69%	0.77% 0.1 pts better	Numerator 1 · Denominator 145
Discharge self-care score	43.59%	53.69% 10.1 pts worse	Numerator 34 · Denominator 78
Discharge mobility score	64.1%	50.94% 13.2 pts better	Numerator 50 · Denominator 78
Pressure ulcers or injuries, new or worsened	2.07%	2.29% 0.2 pts better	Numerator 3 · Denominator 145 · Adjusted rate 1.96%
Healthcare-associated infections requiring hospitalization	5.93%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 139 · Observed rate 5.04% · Lower 95% interval 3.68%
Staff COVID-19 vaccination coverage	2.34%	8.2% 5.9 pts worse	Numerator 4 · Denominator 171
Staff flu vaccination coverage	20.85%	42% 21.1 pts worse	Numerator 49 · Denominator 235
Discharge function score	65.38%	56.45% 8.9 pts better	Numerator 51 · Denominator 78
Transfer of health information to provider	96%	95.95% About the same	Numerator 48 · Denominator 50
Transfer of health information to patient	98.53%	96.28% 2.2 pts better	Numerator 67 · Denominator 68
Resident COVID-19 vaccinations up to date	46.91%	25.2% 21.7 pts better	Numerator 38 · Denominator 81

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	2.2 1.2 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.5 · 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 0.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	88.6%	91.2% 2.6 pts worse	93.4% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 85.9% · Q2 87.0% · Q3 90.5% · Q4 91.0% · 4Q avg 88.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.2%	95.0% 0.2 pts better	95.5% 0.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2%
Percentage of long-stay residents experiencing one or more falls with major injury	1.6%	3.2% 1.6 pts better	3.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.3% · Q3 1.4% · Q4 1.3% · 4Q avg 1.6% · 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	7.0%	5.9% 1.1 pts worse	5.4% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 11.4% · Q3 7.7% · Q4 5.4% · 4Q avg 7.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	2.0%	20.7% 18.7 pts better	19.6% 17.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.4% · Q3 1.4% · Q4 1.3% · 4Q avg 2.0%
Percentage of long-stay residents who received an antipsychotic medication	6.7%	21.4% 14.7 pts better	16.7% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.2% · Q3 3.3% · Q4 4.5% · 4Q avg 6.7% · 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	27.5%	17.9% 9.6 pts worse	16.3% 11.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 56.0% · Q4 17.4% · 4Q avg 27.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.9%	16.2% 3.7 pts worse	14.9% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 26.9% · Q3 10.8% · Q4 8.2% · 4Q avg 19.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	1.1% 0.5 pts worse	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 4.2% · Q3 0.0% · Q4 1.1% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.0%	2.5% 0.5 pts better	1.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.7% · Q3 0.0% · Q4 1.3% · 4Q avg 2.0% · 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 29.1% · Q2 35.6% · Q3 24.3% · Q4 14.5% · 4Q avg 25.7%
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 5.9% · Q3 5.0% · Q4 4.6% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.8%	80.4% 2.4 pts better	81.7% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 78.1% · Q2 87.7% · Q3 84.2% · Q4 81.5% · 4Q avg 82.8%
Percentage of short-stay residents who had an outpatient emergency department visit	11.4%	12.2% 0.8 pts better	12.0% 0.6 pts better	Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.2% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	2.2% 1.3 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.5% · Q3 0.5% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.0%	78.2% 7.8 pts better	79.7% 6.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.7%	24.2% 0.5 pts worse	23.9% 0.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 26.7% · Expected 25.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-24 · Fire 2025-04-24

9 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-03-24 · Fire 2023-03-24

14 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-10-21 · Fire 2021-10-21

2 health deficiencies

Top issue: Infection Control (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-04-24

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 2025-06-06

E · Potential for more than minimal harm 2025-04-24

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-04-24

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-04-24

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 2025-06-06

D · Potential for more than minimal harm 2025-04-24

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-04-24

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 2025-06-06

D · Potential for more than minimal harm 2025-04-24

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-04-24

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 2025-06-06

D · Potential for more than minimal harm 2025-04-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-06

F · Potential for more than minimal harm 2024-12-11

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-01-21

E · Potential for more than minimal harm 2024-12-11

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 2025-01-21

D · Potential for more than minimal harm 2024-12-11

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-01-21

D · Potential for more than minimal harm 2024-12-11

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-01-21

D · Potential for more than minimal harm 2024-12-11

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 2025-01-21

E · Potential for more than minimal harm 2023-03-24

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 2023-04-28

E · Potential for more than minimal harm 2023-03-24

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-04-28