Cycle 1
Health 2024-11-14 · Fire 2024-11-14
6 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Austell, GA
Presbyterian Village
2-star overall rating with 2-star inspections with $64,718 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2000 East-West Connector, Austell, GA
(770) 819-7000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.43
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
746
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0189
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.63
Baseline 19.37% · Performance 18.36% · Measure score 6.63 · Achievement 6.63 · Improvement 3.82
Healthcare-associated infections
4.34
Baseline 7.03% · Performance 6.54% · Measure score 4.34 · Achievement 4.34 · Improvement 1.9
Total nurse turnover
10
Baseline 21.13% · Performance 19.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.79
Baseline 4.83 hours · Performance 4.44 hours · Measure score 4.79 · Achievement 4.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.21% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 12.61% · Lower 95% interval 9% |
| Discharge to community | 51.63% |
50.57%
1.1 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 47.92% · Lower 95% interval 44.05% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 89.47% |
95.27%
5.8 pts worse
|
Numerator 51 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 21.05% |
53.69%
32.6 pts worse
|
Numerator 8 · Denominator 38 |
| Discharge mobility score | 23.68% |
50.94%
27.3 pts worse
|
Numerator 9 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 3.57% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 113 |
| Staff flu vaccination coverage | 1.77% |
42%
40.2 pts worse
|
Numerator 2 · Denominator 113 |
| Discharge function score | 23.68% |
56.45%
32.8 pts worse
|
Numerator 9 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 2 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
2.2
1.7 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 2.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.8 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 56.5% |
91.2%
34.7 pts worse
|
93.4%
36.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.9% · Q2 55.0% · Q3 42.6% · Q4 38.6% · 4Q avg 56.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.6% |
95.0%
17.4 pts worse
|
95.5%
17.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 1.9% · Q4 0.0% · 4Q avg 1.7% · 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 | 7.3% |
5.9%
1.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.8% · Q3 14.0% · Q4 4.3% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
20.7%
6.7 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 13.2% · Q3 12.5% · Q4 12.5% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.7% |
21.4%
2.3 pts worse
|
16.7%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 24.3% · Q3 25.0% · Q4 26.3% · 4Q avg 23.7% · 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 | 32.0% |
17.9%
14.1 pts worse
|
16.3%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 34.3% · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
16.2%
6.6 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 38.6% · Q3 31.7% · Q4 4.9% · 4Q avg 22.8% · 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 | 2.2% |
2.5%
0.3 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 6.1% · Q4 1.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
16.1%
5.3 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 26.7% · Q3 23.7% · Q4 14.1% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
6.2%
2.7 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.3% · Q3 14.1% · Q4 5.8% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.9% |
80.4%
25.5 pts worse
|
81.7%
26.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.5% · Q2 52.2% · Q3 47.4% · Q4 55.7% · 4Q avg 54.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
12.2%
2.3 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 12.5% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.1% |
78.2%
27.1 pts worse
|
79.7%
28.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
24.2%
3.8 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 16.7% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2019-02-28 · Fire 2019-02-28
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-29
D · Potential for more than minimal harm
2024-11-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-29
D · Potential for more than minimal harm
2024-11-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-29
D · Potential for more than minimal harm
2022-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-07-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-26
E · Potential for more than minimal harm
2019-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-27
E · Potential for more than minimal harm
2019-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-03-27
E · Potential for more than minimal harm
2019-02-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-03-27
D · Potential for more than minimal harm
2019-02-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-03-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-29
F · Potential for more than minimal harm
2024-11-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-29
F · Potential for more than minimal harm
2024-11-14
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-12-29
D · Potential for more than minimal harm
2024-11-14
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 2024-12-29
D · Potential for more than minimal harm
2024-11-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-29
D · Potential for more than minimal harm
2024-11-14
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 2025-02-07
D · Potential for more than minimal harm
2022-07-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-26
D · Potential for more than minimal harm
2019-02-28
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 2019-03-27
Penalties and ownership
What sits behind the stars
$64,718
2024-11-14
Fine
Fine · fine $64,718
Fine
$0
2024-11-14
Payment Denial
Payment Denial · denial start 2025-01-22 · 16 days
16 day denial
Ownership
Presbyterian Village, Austell, Inc.
5% Or Greater Direct Ownership Interest · Organization
Barglof, Mark
Operational/Managerial Control · Individual
Haire, Deanna
Corporate Officer · Individual
Lawton, Rodrick
Operational/Managerial Control · Individual
Meyer, Tammy
Corporate Officer · Individual
Patterson, Stephen
Corporate Officer · Individual
Pearce, Chad
Corporate Officer · Individual
Polk, Elizabeth G
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Anderson Mill Center For Nursing And Healing LLC
Austell, GA
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Powder Springs Center For Nursing & Healing
Powder Springs, GA
2-star overall rating with 2-star inspections with $16,802 in total fines with 4 recent health deficiencies
#3
Pruitthealth - Austell
Austell, GA
1-star overall rating with 1-star inspections with 16 recent health deficiencies
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