Cycle 1
Health 2025-08-28 · Fire 2025-08-28
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Woodstock, GA
Woodstock Center for Nursing and Healing LLC
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
105 Arnold Mill Road, Woodstock, GA
(770) 926-0016
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
171
Certified beds
Average residents
129
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Empire Care Centers
Operator or chain grouping
Approved since
1989-07-01
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
0.54
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.48
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
2.87
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.16
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,373
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 25.59% · Performance 25.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.69
Baseline 9.12% · Performance 8.63% · Measure score 0.69 · Achievement 0 · Improvement 0.69
Total nurse turnover
0
Baseline 67.20% · Performance 78.46% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.73
Baseline 3.50 hours · Performance 3.57 hours · Measure score 1.73 · Achievement 1.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.48% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 200 · Observed rate 16.5% · Lower 95% interval 10.47% |
| Discharge to community | 56.29% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 46.52% · Lower 95% interval 47.33% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.52% |
95.27%
2.2 pts better
|
Numerator 157 · Denominator 161 |
| Falls with major injury | 1.86% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 161 |
| Discharge self-care score | 57.53% |
53.69%
3.8 pts better
|
Numerator 42 · Denominator 73 |
| Discharge mobility score | 57.53% |
50.94%
6.6 pts better
|
Numerator 42 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 5.59% |
2.29%
3.3 pts worse
|
Numerator 9 · Denominator 161 · Adjusted rate 5.33% |
| Healthcare-associated infections requiring hospitalization | 8.63% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 11.68% · Lower 95% interval 6.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 144 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 54.79% |
56.45%
1.7 pts worse
|
Numerator 40 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 61 · Denominator 61 |
| Transfer of health information to patient | 98.28% |
96.28%
2 pts better
|
Numerator 57 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 7.23% |
25.2%
18 pts worse
|
Numerator 6 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.0% |
91.2%
15.2 pts worse
|
93.4%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 80.6% · Q3 75.2% · Q4 64.5% · 4Q avg 76.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 52.9% |
95.0%
42.1 pts worse
|
95.5%
42.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 52.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.2%
0.4 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 4.6% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
9.6%
3.7 pts better
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 21.3% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
5.9%
4.4 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 3.7% · Q3 18.0% · Q4 6.8% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
20.7%
11.6 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 8.3% · Q3 7.7% · Q4 8.7% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
21.4%
4.3 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 15.2% · Q3 16.9% · Q4 17.1% · 4Q avg 17.1% · 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 | 41.6% |
17.9%
23.7 pts worse
|
16.3%
25.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.8% · Q2 25.3% · Q3 33.9% · Q4 51.9% · 4Q avg 41.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 38.1% |
16.2%
21.9 pts worse
|
14.9%
23.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.2% · Q2 36.1% · Q3 32.1% · Q4 40.9% · 4Q avg 38.1% · 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 0.0% · Q3 2.2% · Q4 0.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.5%
0.2 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.1% · Q3 2.8% · Q4 2.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
16.1%
13.3 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 32.4% · Q3 20.0% · Q4 30.2% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
6.2%
1 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.6% · Q3 6.4% · Q4 7.1% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
80.4%
30.4 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.3% · Q2 47.4% · Q3 42.6% · Q4 48.5% · 4Q avg 50.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.2%
3.1 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.8% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
2.2%
2.2 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.8% · Q3 5.3% · Q4 5.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 35.9% |
78.2%
42.3 pts worse
|
79.7%
43.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 35.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
24.2%
7.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 37.4% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-05-04 · Fire 2022-05-04
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-28
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 2025-11-21
D · Potential for more than minimal harm
2025-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-21
D · Potential for more than minimal harm
2024-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-28
C · Minimal harm
2022-05-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-08-28
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-08-28
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 2025-10-07
D · Potential for more than minimal harm
2025-08-28
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 2025-10-07
D · Potential for more than minimal harm
2025-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-07
E · Potential for more than minimal harm
2024-05-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-16
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 2024-06-30
D · Potential for more than minimal harm
2024-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-16
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 2024-06-30
D · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-30
J · Immediate jeopardy
2022-05-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-06-24
J · Immediate jeopardy
2022-05-04
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 2022-06-24
J · Immediate jeopardy
2022-05-04
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 2022-06-24
J · Immediate jeopardy
2022-05-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-24
J · Immediate jeopardy
2022-05-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-06-24
F · Potential for more than minimal harm
2022-05-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-24
F · Potential for more than minimal harm
2022-05-04
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-06-24
Penalties and ownership
What sits behind the stars
Ownership
Ga Cy2 Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Coopeland, Tanya
Operational/Managerial Control · Individual
Donath, Barry
5% Or Greater Indirect Ownership Interest · Individual
Donath, Barry
Operational/Managerial Control · Individual
Ellis, Renee
Operational/Managerial Control · Individual
Empire Care Centers LLC
Operational/Managerial Control · Organization
Ensh Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Facyson, Maurice
Operational/Managerial Control · Individual
Gilbert, Michael
Operational/Managerial Control · Individual
Goodwin, Annette
Operational/Managerial Control · Individual
Hansen, Lisa
Operational/Managerial Control · Individual
Hardy, Leanthony
Operational/Managerial Control · Individual
Heller, Shlomo
5% Or Greater Indirect Ownership Interest · Individual
Heller, Shlomo
Operational/Managerial Control · Individual
Mathew, Shemily
Operational/Managerial Control · Individual
Nussbaum, Ephraim
5% Or Greater Indirect Ownership Interest · Individual
Nussbaum, Ephraim
Operational/Managerial Control · Individual
Shield, Katrina
Operational/Managerial Control · Individual
Sone-Ebeloue, Gladys
Operational/Managerial Control · Individual
Swerdloff, Aryeh
5% Or Greater Indirect Ownership Interest · Individual
Swerdloff, Aryeh
Operational/Managerial Control · Individual
Tiggs, Dorenda
Operational/Managerial Control · Individual
Vasil, Jennifer
Operational/Managerial Control · Individual
Waters, Tenisha
Operational/Managerial Control · Individual
Watts, Kristin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Marietta Center For Nursing And Healing
Marietta, GA
1-star overall rating with 2-star inspections with $7,901 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Tower Road Post Acute, LLC
Marietta, GA
1-star overall rating with 2-star inspections with 23 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Cherokee Center For Nursing And Healing LLC
Canton, GA
1-star overall rating with 1-star inspections with $185,650 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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