Powder Springs, GA

Powder Springs Center For Nursing & Healing

2-star overall rating with 2-star inspections with $16,802 in total fines with 4 recent health deficiencies

3460 Powder Springs Road, Powder Springs, GA

(770) 439-9199

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

208

Certified beds

Average residents

182

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Empire Care Centers

Operator or chain grouping

Approved since

1993-02-25

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

0.43

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

1.91

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

1.42

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.85

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.39

CMS adjusted RN staffing hours

Adjusted total hours

3.04

CMS adjusted total nurse staffing hours

Case-mix index

1.50

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,853

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

Performance score

25.46

Composite VBP score used to determine payment impact.

Payment multiplier

0.9838

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.37% · Performance 22.79% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.3

Baseline 8.19% · Performance 7.30% · Measure score 2.3 · Achievement 1.80 · Improvement 2.3

Total nurse turnover

7.42

Performance 33.33% · Measure score 7.42 · Achievement 7.42 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.46

Baseline 2.73 hours · Performance 3.02 hours · Measure score 0.46 · Achievement 0 · Improvement 0.46

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.88%	10.72% 1.2 pts worse	No Different than the National Rate · Eligible stays 275 · Observed rate 15.27% · Lower 95% interval 9.22%
Discharge to community	50.33%	50.57% 0.2 pts worse	No Different than the National Rate · Eligible stays 268 · Observed rate 38.81% · Lower 95% interval 42.79%
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	94.96%	95.27% 0.3 pts worse	Numerator 226 · Denominator 238
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 238
Discharge self-care score	43.9%	53.69% 9.8 pts worse	Numerator 54 · Denominator 123
Discharge mobility score	28.46%	50.94% 22.5 pts worse	Numerator 35 · Denominator 123
Pressure ulcers or injuries, new or worsened	1.68%	2.29% 0.6 pts better	Numerator 4 · Denominator 238 · Adjusted rate 1.25%
Healthcare-associated infections requiring hospitalization	7.3%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 177 · Observed rate 8.47% · Lower 95% interval 5.29%
Staff COVID-19 vaccination coverage	4.27%	8.2% 3.9 pts worse	Numerator 9 · Denominator 211
Staff flu vaccination coverage	1.7%	42% 40.3 pts worse	Numerator 4 · Denominator 235
Discharge function score	38.21%	56.45% 18.2 pts worse	Numerator 47 · Denominator 123
Transfer of health information to provider	96.05%	95.95% 0.1 pts better	Numerator 73 · Denominator 76
Transfer of health information to patient	98.32%	96.28% 2 pts better	Numerator 117 · Denominator 119
Resident COVID-19 vaccinations up to date	22.06%	25.2% 3.1 pts worse	Numerator 30 · Denominator 136

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	2.2 0.4 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	2.0 0.5 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.9%	91.2% 6.7 pts better	93.4% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 97.9% · Q4 95.1% · 4Q avg 97.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.1%	95.0% 3.1 pts better	95.5% 2.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1%
Percentage of long-stay residents experiencing one or more falls with major injury	1.9%	3.2% 1.3 pts better	3.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.7% · Q3 1.4% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	9.6% 9 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	8.1%	5.9% 2.2 pts worse	5.4% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.8% · Q3 5.4% · Q4 7.6% · 4Q avg 8.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.2%	20.7% 8.5 pts better	19.6% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 11.3% · Q3 11.2% · Q4 14.4% · 4Q avg 12.2%
Percentage of long-stay residents who received an antipsychotic medication	14.9%	21.4% 6.5 pts better	16.7% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 15.9% · Q3 14.9% · Q4 16.8% · 4Q avg 14.9% · 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	26.0%	17.9% 8.1 pts worse	16.3% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 34.8% · Q3 25.8% · Q4 23.1% · 4Q avg 26.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.7%	16.2% 0.5 pts worse	14.9% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 14.7% · Q3 18.7% · Q4 16.8% · 4Q avg 16.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	1.1% 0.7 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.6% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.3%	2.5% 1.2 pts better	1.7% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.8% · Q3 2.2% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.9%	16.1% 4.8 pts worse	19.8% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 23.7% · Q3 13.9% · Q4 22.1% · 4Q avg 20.9%
Percentage of long-stay residents with pressure ulcers	5.8%	6.2% 0.4 pts better	5.1% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.6% · Q3 5.1% · Q4 8.9% · 4Q avg 5.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.2%	80.4% 9.8 pts better	81.7% 8.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 91.7% · Q3 89.3% · Q4 85.0% · 4Q avg 90.2%
Percentage of short-stay residents who had an outpatient emergency department visit	12.8%	12.2% 0.6 pts worse	12.0% 0.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 13.3% · Expected 11.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	2.2% 1.6 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.9% · Q4 0.5% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.7%	78.2% 4.5 pts better	79.7% 3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.4%	24.2% 0.2 pts worse	23.9% 0.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 26.0% · Expected 25.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-27 · Fire 2024-06-27

4 health deficiencies

Top issue: Administration (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-04-22 · Fire 2022-04-22

20 health deficiencies

Top issue: Infection Control (5 deficiencies)

1 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2018-11-29 · Fire 2018-11-29

0 health deficiencies

No concentrated health issue counts in this cycle.

7 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2022-04-22

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2022-06-06

F · Potential for more than minimal harm 2018-11-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-01-27

F · Potential for more than minimal harm 2018-11-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-01-27

E · Potential for more than minimal harm 2018-11-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-01-27

E · Potential for more than minimal harm 2018-11-29

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-01-27

D · Potential for more than minimal harm 2018-11-29

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-01-27

D · Potential for more than minimal harm 2018-11-29

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2019-01-27

D · Potential for more than minimal harm 2018-11-29

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2019-01-27

Inspection history

Recent health citations

F · Potential for more than minimal harm 2026-01-09

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 2026-02-14

D · Potential for more than minimal harm 2026-01-09

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 2026-02-14

C · Minimal harm 2026-01-09

F848 · Administration Deficiencies

Health

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected 2026-02-14

E · Potential for more than minimal harm 2024-06-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-11

J · Immediate jeopardy 2024-04-15

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2022-08-12

J · Immediate jeopardy 2024-04-15

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2022-08-12

F · Potential for more than minimal harm 2024-04-15

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 2024-05-20

F · Potential for more than minimal harm 2024-04-15

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-05-20

F · Potential for more than minimal harm 2024-04-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-20

F · Potential for more than minimal harm 2024-04-15

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-05-20

E · Potential for more than minimal harm 2024-04-15

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 2024-05-20