Cycle 1
Health 2024-10-18 · Fire 2024-10-18
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Winder, GA
Winder Center For Nursing And Healing
1-star overall rating with 1-star inspections with $17,074 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
263 E May Street, Winder, GA
(770) 867-2108
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
163
Certified beds
Average residents
141
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Empire Care Centers
Operator or chain grouping
Approved since
1993-01-01
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
0.31
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.84
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
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.71% · Performance 22.99% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.04% · Performance 8.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 52.11% · Performance 63.91% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.22 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 16.25% · Lower 95% interval 9.21% |
| Discharge to community | 51.77% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 40.94% · Lower 95% interval 41.83% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.74% |
95.27%
3.5 pts better
|
Numerator 157 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 58.7% |
53.69%
5 pts better
|
Numerator 54 · Denominator 92 |
| Discharge mobility score | 41.3% |
50.94%
9.6 pts worse
|
Numerator 38 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 2.52% |
2.29%
0.2 pts worse
|
Numerator 4 · Denominator 159 · Adjusted rate 2.13% |
| Healthcare-associated infections requiring hospitalization | 8.89% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 12.6% · Lower 95% interval 5.69% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 127 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 64.13% |
56.45%
7.7 pts better
|
Numerator 59 · Denominator 92 |
| Transfer of health information to provider | 92.98% |
95.95%
3 pts worse
|
Numerator 53 · Denominator 57 |
| Transfer of health information to patient | 95.77% |
96.28%
0.5 pts worse
|
Numerator 68 · Denominator 71 |
| Resident COVID-19 vaccinations up to date | 1.2% |
25.2%
24 pts worse
|
Numerator 1 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
91.2%
4.1 pts better
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 94.4% · Q3 97.5% · Q4 100.0% · 4Q avg 95.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
95.0%
1.3 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.2%
2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 1.7% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
9.6%
4.3 pts better
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.3% · Q3 0.9% · Q4 1.9% · 4Q avg 5.3% |
| 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 7.5% · Q2 3.7% · Q3 9.6% · Q4 8.6% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
20.7%
2 pts better
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 19.1% · Q3 15.4% · Q4 15.9% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
21.4%
1.5 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 23.2% · Q3 22.1% · Q4 20.9% · 4Q avg 22.9% · 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 | 20.4% |
17.9%
2.5 pts worse
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 24.3% · Q3 19.5% · Q4 17.4% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
16.2%
2.5 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 22.2% · Q3 13.5% · Q4 16.5% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.1%
1 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.6% · Q3 1.5% · Q4 2.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 0.8% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
16.1%
8 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 23.6% · Q3 23.9% · Q4 18.1% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.2%
2.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.7% · Q3 4.7% · Q4 3.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
80.4%
12.8 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 93.8% · Q3 95.7% · Q4 97.8% · 4Q avg 93.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
12.2%
1.9 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 11.2% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.2%
0.5 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.6% · Q3 2.5% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.9% |
78.2%
7.7 pts better
|
79.7%
6.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
24.2%
0.9 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 26.4% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-11 · Fire 2022-08-11
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-05-17 · Fire 2019-05-17
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-18
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 2024-11-21
D · Potential for more than minimal harm
2024-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-21
F · Potential for more than minimal harm
2022-08-11
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-11
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-09-25
E · Potential for more than minimal harm
2022-08-11
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 2022-09-25
E · Potential for more than minimal harm
2022-08-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-25
Inspection history
Recent health citations
J · Immediate jeopardy
2024-10-18
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 2024-11-21
J · Immediate jeopardy
2024-10-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-18
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 2024-11-21
D · Potential for more than minimal harm
2024-10-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-18
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-11-21
F · Potential for more than minimal harm
2022-08-11
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 2022-09-25
D · Potential for more than minimal harm
2022-08-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-25
E · Potential for more than minimal harm
2019-05-17
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 2019-07-01
D · Potential for more than minimal harm
2019-05-17
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 2019-07-01
Penalties and ownership
What sits behind the stars
$8,537
2024-10-18
Fine
Fine · fine $8,537
Fine
$8,537
2024-10-18
Fine
Fine · fine $8,537
Fine
Ownership
Ensh Consulting LLC
5% Or Greater Direct Ownership Interest · Organization
Heller, Shlomo
5% Or Greater Indirect Ownership Interest · Individual
Nussbaum, Ephraim
5% Or Greater Indirect Ownership Interest · Individual
Swerdloff, Aryeh
5% Or Greater Indirect Ownership Interest · Individual
Donath, Barry
W-2 Managing Employee · Individual
Empire Care Centers LLC
Operational/Managerial Control · Organization
Heller, Shlomo
Operational/Managerial Control · Individual
Heller, Shlomo
Corporate Officer · Individual
Ng, Scott
Operational/Managerial Control · Individual
Ng, Scott
W-2 Managing Employee · Individual
Nussbaum, Ephraim
Operational/Managerial Control · Individual
Swerdloff, Aryeh
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Park Place Nursing Facility
Monroe, GA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Mesun Health And Rehabilitation Center
Lawrenceville, GA
2-star overall rating with 2-star inspections with $4,017 in total fines with 9 recent health deficiencies
#3
University Nursing & Rehab Ctr
Athens, GA
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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