Cycle 1
Health 2025-04-03 · Fire 2025-04-03
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Athens, GA
University Nursing & Rehab Ctr
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
180 Epps Bridge Rd, Athens, GA
(706) 549-5382
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cypress Skilled Nursing
Operator or chain grouping
Approved since
1990-01-01
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
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
0.10
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.91
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.11
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
94%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
79%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,140
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.16% · Performance 24.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.46
Baseline 10.67% · Performance 7.86% · Measure score 4.46 · Achievement 0 · Improvement 4.46
Total nurse turnover
0
Baseline 72.83% · Performance 77.06% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.02
Baseline 2.89 hours · Performance 3.33 hours · Measure score 1.02 · Achievement 0.89 · Improvement 1.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 11.11% · Lower 95% interval 7.35% |
| Discharge to community | 53.31% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 40.45% · Lower 95% interval 41.38% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 56 · Denominator 60 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 60 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 9 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 2 · Denominator 60 · Adjusted rate 3.2% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 4.81% |
| Staff COVID-19 vaccination coverage | 5.06% |
8.2%
3.1 pts worse
|
Numerator 4 · Denominator 79 |
| Staff flu vaccination coverage | 35.19% |
42%
6.8 pts worse
|
Numerator 57 · Denominator 162 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 14 · Denominator 22 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 85% |
96.28%
11.3 pts worse
|
Numerator 17 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 30.3% |
25.2%
5.1 pts better
|
Numerator 10 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.0
0.9 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.1% |
91.2%
16.1 pts worse
|
93.4%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.0% · Q2 72.2% · Q3 78.3% · Q4 84.6% · 4Q avg 75.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
95.0%
1.7 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 3.3% · Q4 2.2% · 4Q avg 2.1% · 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 | 4.7% |
5.9%
1.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.2% · Q3 6.0% · Q4 3.7% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
20.7%
0.8 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 22.2% · Q3 22.1% · Q4 17.6% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.8% |
21.4%
3.4 pts worse
|
16.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 27.3% · Q3 21.7% · Q4 24.6% · 4Q avg 24.8% · 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 | 19.4% |
17.9%
1.5 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 18.4% · Q3 8.6% · Q4 13.3% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
16.2%
4 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 28.8% · Q3 16.9% · Q4 17.8% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.1%
About the same
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.9% · Q3 0.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
16.1%
11 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 24.1% · Q3 25.0% · Q4 27.7% · 4Q avg 27.1% |
| 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 4.6% · Q2 8.8% · Q3 5.8% · Q4 3.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.8% |
80.4%
15.6 pts worse
|
81.7%
16.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.6% · Q2 45.5% · Q3 66.3% · Q4 89.9% · 4Q avg 64.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
12.2%
6.9 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 23.6% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
2.2%
1.8 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.2% · Q3 3.7% · Q4 3.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.4% |
78.2%
24.8 pts worse
|
79.7%
26.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.1% |
24.2%
12.9 pts worse
|
23.9%
13.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.1% · Observed 44.4% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-09 · Fire 2023-12-09
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-06-20 · Fire 2022-06-20
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-05-05
F · Potential for more than minimal harm
2025-04-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-04-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-04-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-05
F · Potential for more than minimal harm
2025-04-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-04-03
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-05
F · Potential for more than minimal harm
2023-12-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
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 2024-01-23
D · Potential for more than minimal harm
2023-12-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-03
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 2025-05-05
E · Potential for more than minimal harm
2025-04-03
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 2025-05-05
D · Potential for more than minimal harm
2025-04-03
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 2025-05-05
F · Potential for more than minimal harm
2023-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-23
F · Potential for more than minimal harm
2023-12-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
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 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-09
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-05-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-16
K · Immediate jeopardy
2022-06-20
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-20
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 2022-08-12
D · Potential for more than minimal harm
2022-06-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-20
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-20
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 2022-08-12
D · Potential for more than minimal harm
2022-06-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-20
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 2022-08-12
Penalties and ownership
What sits behind the stars
Ownership
Cypress Skilled Nursing LLC
5% Or Greater Direct Ownership Interest · Organization
Bender, Sara
Operational/Managerial Control · Individual
Cypress Operating LLC
5% Or Greater Indirect Ownership Interest · Organization
Cypress Skilled Nursing LLC
Operational/Managerial Control · Organization
Enin Tr
5% Or Greater Indirect Ownership Interest · Organization
Macatula, Maria
Operational/Managerial Control · Individual
Nordholm, Katherine
Operational/Managerial Control · Individual
Ovits, Isaac
Operational/Managerial Control · Individual
Patterson, Dianne
Operational/Managerial Control · Individual
Pope, Dorothy
Operational/Managerial Control · Individual
Pughsley, Sonia
Operational/Managerial Control · Individual
Reddick, Joane
Operational/Managerial Control · Individual
Sims, Demarious
Operational/Managerial Control · Individual
Snf Tr
5% Or Greater Indirect Ownership Interest · Organization
Udo, Emem
Operational/Managerial Control · Individual
Vaughan, Alyssa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Presbyterian Village - Athens
Athens, GA
2-star overall rating with 2-star inspections with $18,545 in total fines with 1 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - Athens Heritage
Athens, GA
2-star overall rating with 3-star inspections with $16,801 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Grandview
Athens, GA
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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