Cycle 1
Health 2025-06-13 · Fire 2025-06-13
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fayetteville, GA
Fayetteville Center For Nursing & Healing LLC
2-star overall rating with 3-star inspections with $11,171 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
110 Brandywine Boulevard, Fayetteville, GA
(770) 461-2928
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
162
Certified beds
Average residents
145
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Empire Care Centers
Operator or chain grouping
Approved since
1989-04-20
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
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
0.30
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,520
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.18
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 20.72% · Performance 22.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.67
Baseline 11.07% · Performance 9.75% · Measure score 1.67 · Achievement 0 · Improvement 1.67
Total nurse turnover
0
Performance 75.00% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.32 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.76% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 17.16% · Lower 95% interval 9.57% |
| Discharge to community | 50.21% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 40.22% · Lower 95% interval 42.59% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.54% |
95.27%
4.3 pts better
|
Numerator 218 · Denominator 219 |
| Falls with major injury | 2.28% |
0.77%
1.5 pts worse
|
Numerator 5 · Denominator 219 |
| Discharge self-care score | 53.76% |
53.69%
0.1 pts better
|
Numerator 50 · Denominator 93 |
| Discharge mobility score | 49.46% |
50.94%
1.5 pts worse
|
Numerator 46 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 3.2% |
2.29%
0.9 pts worse
|
Numerator 7 · Denominator 219 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 9.75% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 16.07% · Lower 95% interval 7.12% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 169 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 322 |
| Discharge function score | 49.46% |
56.45%
7 pts worse
|
Numerator 46 · Denominator 93 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 92 · Denominator 92 |
| Transfer of health information to patient | 98.94% |
96.28%
2.7 pts better
|
Numerator 93 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 23.85% |
25.2%
1.3 pts worse
|
Numerator 31 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.2
1.2 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 4.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 57.4% |
91.2%
33.8 pts worse
|
93.4%
36 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.2% · Q2 53.7% · Q3 55.1% · Q4 55.6% · 4Q avg 57.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.0% |
95.0%
12 pts worse
|
95.5%
12.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.0% |
| 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 3.3% · Q2 2.1% · Q3 1.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
9.6%
8 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.1% · Q4 1.2% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.9%
1.6 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 9.0% · Q3 7.9% · Q4 6.4% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
20.7%
11.6 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 9.3% · Q3 9.9% · Q4 9.8% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
21.4%
14.2 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.4% · Q3 6.1% · Q4 4.3% · 4Q avg 7.2% · 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 | 26.5% |
17.9%
8.6 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
16.2%
9.8 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 35.1% · Q3 25.0% · Q4 20.8% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.1%
0.9 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.5%
1.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
16.1%
9.4 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 23.8% · Q3 36.4% · Q4 19.1% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.2%
0.7 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.8% · Q3 5.2% · Q4 4.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.1% |
80.4%
14.3 pts worse
|
81.7%
15.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.9% · Q2 63.8% · Q3 65.7% · Q4 69.7% · 4Q avg 66.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
12.2%
4.2 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 10.0% · Expected 13.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.2%
1.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.0% · Q3 1.0% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.1% |
78.2%
19.1 pts worse
|
79.7%
20.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
24.2%
1.9 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 34.3% · Expected 31.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-04-01 · Fire 2022-04-01
9 health deficiencies
Top issue: Quality of Life and Care (4 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
2025-06-13
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
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 2025-12-09
D · Potential for more than minimal harm
2025-11-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-11-19
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 2025-12-09
D · Potential for more than minimal harm
2025-11-19
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-11-19
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 2025-12-09
D · Potential for more than minimal harm
2025-11-19
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 2025-12-09
D · Potential for more than minimal harm
2025-11-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-06-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Not marked corrected
D · Potential for more than minimal harm
2025-06-13
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.
Not marked corrected
D · Potential for more than minimal harm
2025-06-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Not marked corrected
D · Potential for more than minimal harm
2025-06-13
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.
Not marked corrected
D · Potential for more than minimal harm
2025-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2024-02-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-17
D · Potential for more than minimal harm
2024-02-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-17
G · Actual harm
2023-11-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-10
D · Potential for more than minimal harm
2023-11-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-10
D · Potential for more than minimal harm
2023-11-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-10
D · Potential for more than minimal harm
2023-11-09
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 2023-12-10
D · Potential for more than minimal harm
2023-11-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-10
D · Potential for more than minimal harm
2022-04-01
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 2022-05-01
D · Potential for more than minimal harm
2022-04-01
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 2022-05-01
D · Potential for more than minimal harm
2022-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-01
D · Potential for more than minimal harm
2022-04-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-05-01
Penalties and ownership
What sits behind the stars
$3,728
2023-11-09
Fine
Fine · fine $3,728
Fine
$7,443
2023-11-09
Fine
Fine · fine $7,443
Fine
Ownership
Ga4 Opco Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Empire Care Centers LLC
Operational/Managerial Control · Organization
Ensh Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Heller, Shlomo
5% Or Greater Indirect Ownership Interest · Individual
Heller, Shlomo
Operational/Managerial Control · Individual
Heller, Shlomo
Corporate Officer · Individual
Nussbaum, Ephraim
5% Or Greater Indirect Ownership Interest · Individual
Nussbaum, Ephraim
Operational/Managerial Control · Individual
Robinson, Kawanna
Operational/Managerial Control · Individual
Robinson, Kawanna
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Southland Health And Rehabilitation
Peachtree City, GA
3-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies
#2
Christian City Rehabilitation Center
Union City, GA
2-star overall rating with 2-star inspections with 20 recent health deficiencies
#3
Riverdale Center For Nursing And Healing
Riverdale, GA
2-star overall rating with 2-star inspections with $10,050 in total fines with 6 recent health deficiencies
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