Roswell, GA

Roswell Center For Nursing And Healing LLC

1-star overall rating with 1-star inspections with $206,486 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

1109 Green Street, Roswell, GA

(770) 998-1802

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

268

Certified beds

Average residents

178

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Cypress Skilled Nursing

Operator or chain grouping

Approved since

1989-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

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

0.26

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

1.08

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

1.80

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.14

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.71

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.23

CMS adjusted RN staffing hours

Adjusted total hours

2.82

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

78%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,492

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

Performance score

4.53

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

Baseline 20.01% · Performance 21.84% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.21

Baseline 6.19% · Performance 7.47% · Measure score 1.21 · Achievement 1.21 · Improvement 0

Total nurse turnover

Baseline 71.60% · Performance 85.97% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0.60

Baseline 2.98 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0.47

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.6%	10.72% 2.9 pts worse	No Different than the National Rate · Eligible stays 120 · Observed rate 18.33% · Lower 95% interval 10.4%
Discharge to community	37.83%	50.57% 12.7 pts worse	Worse than the National Rate · Eligible stays 119 · Observed rate 28.57% · Lower 95% interval 30.05%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	94.5%	95.27% 0.8 pts worse	Numerator 103 · Denominator 109
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 109
Discharge self-care score	33.9%	53.69% 19.8 pts worse	Numerator 20 · Denominator 59
Discharge mobility score	18.64%	50.94% 32.3 pts worse	Numerator 11 · Denominator 59
Pressure ulcers or injuries, new or worsened	4.59%	2.29% 2.3 pts worse	Numerator 5 · Denominator 109 · Adjusted rate 3.09%
Healthcare-associated infections requiring hospitalization	7.47%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 75 · Observed rate 9.33% · Lower 95% interval 4.94%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 170
Staff flu vaccination coverage	13.98%	42% 28 pts worse	Numerator 26 · Denominator 186
Discharge function score	25.42%	56.45% 31 pts worse	Numerator 15 · Denominator 59
Transfer of health information to provider	84.78%	95.95% 11.2 pts worse	Numerator 39 · Denominator 46
Transfer of health information to patient	85%	96.28% 11.3 pts worse	Numerator 17 · Denominator 20
Resident COVID-19 vaccinations up to date	10%	25.2% 15.2 pts worse	Numerator 6 · Denominator 60

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	2.2 0.2 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.0 0.3 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	70.2%	91.2% 21 pts worse	93.4% 23.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 66.5% · Q2 70.2% · Q3 73.1% · Q4 71.3% · 4Q avg 70.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.7%	95.0% 0.3 pts worse	95.5% 0.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of long-stay residents experiencing one or more falls with major injury	3.1%	3.2% 0.1 pts better	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.2% · Q3 4.0% · Q4 3.0% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.2%	9.6% 9.4 pts better	11.4% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2%
Percentage of long-stay residents who lose too much weight	6.0%	5.9% 0.1 pts worse	5.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.0% · Q3 7.7% · Q4 2.9% · 4Q avg 6.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.5%	20.7% 7.8 pts worse	19.6% 8.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 30.3% · Q3 26.7% · Q4 31.2% · 4Q avg 28.5%
Percentage of long-stay residents who received an antipsychotic medication	28.0%	21.4% 6.6 pts worse	16.7% 11.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 28.2% · Q3 25.4% · Q4 27.6% · 4Q avg 28.0% · 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	21.6%	17.9% 3.7 pts worse	16.3% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 28.3% · Q3 19.4% · Q4 24.2% · 4Q avg 21.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.2%	16.2% 5 pts worse	14.9% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 20.3% · Q3 22.6% · Q4 26.7% · 4Q avg 21.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	1.1% 0.3 pts better	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 1.9% · Q4 0.4% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.3%	2.5% 0.2 pts better	1.7% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.3% · Q3 3.0% · Q4 3.1% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.0%	16.1% 5.9 pts worse	19.8% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 26.7% · Q3 24.5% · Q4 25.0% · 4Q avg 22.0%
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 6.3% · Q2 4.0% · Q3 5.9% · Q4 5.7% · 4Q avg 5.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	75.5%	80.4% 4.9 pts worse	81.7% 6.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 76.6% · Q2 77.9% · Q3 80.6% · Q4 67.2% · 4Q avg 75.5%
Percentage of short-stay residents who had an outpatient emergency department visit	15.7%	12.2% 3.5 pts worse	12.0% 3.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 18.1% · Expected 12.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.6%	2.2% 0.4 pts worse	1.6% 1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.0% · Q3 0.0% · Q4 1.3% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.7%	78.2% 1.5 pts worse	79.7% 3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.0%	24.2% 1.8 pts worse	23.9% 2.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 33.6% · Expected 30.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-20 · Fire 2025-02-20

13 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-03-09 · Fire 2023-03-09

9 health deficiencies

Top issue: Infection Control (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2020-02-27 · Fire 2020-02-27

7 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-20

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-20

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-20

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-20

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-02-27

D · Potential for more than minimal harm 2023-03-09

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-04-20

F · Potential for more than minimal harm 2020-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-04-10

E · Potential for more than minimal harm 2020-02-27

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2020-04-10

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-07-02

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 2025-07-29

D · Potential for more than minimal harm 2025-07-02

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 2025-07-29

J · Immediate jeopardy 2025-02-20

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 2025-04-14

J · Immediate jeopardy 2025-02-20

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 2025-04-14

J · Immediate jeopardy 2025-02-20

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2025-04-14

G · Actual harm 2025-02-20

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 2025-04-14

G · Actual harm 2025-02-20

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-04-14

E · Potential for more than minimal harm 2025-02-20

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-04-14

E · Potential for more than minimal harm 2025-02-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-14

E · Potential for more than minimal harm 2025-02-20

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-02-20

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 2025-04-14

D · Potential for more than minimal harm 2025-02-20

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-02-20

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-04-14

E · Potential for more than minimal harm 2023-03-09

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 2023-04-20

E · Potential for more than minimal harm 2023-03-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-03-09

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

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 2023-04-20

D · Potential for more than minimal harm 2023-03-09

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 2023-04-20

D · Potential for more than minimal harm 2023-03-09

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 2023-04-20

D · Potential for more than minimal harm 2023-03-09

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-09

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2023-04-20

D · Potential for more than minimal harm 2020-02-27

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-02-27

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 2020-04-10

D · Potential for more than minimal harm 2020-02-27

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-02-27

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 2020-04-10

D · Potential for more than minimal harm 2020-02-27

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-02-27

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 2020-04-10

D · Potential for more than minimal harm 2020-02-27

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2020-04-10

Penalties and ownership

What sits behind the stars

$206,486 2025-02-20

Fine

Fine · fine $206,486

Fine