15 health deficiencies
Top issue: Resident Rights (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Tucker, GA
1-star overall rating with 1-star inspections with $47,466 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4608 Lawrenceville Highway, Tucker, GA
(770) 491-9444
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
Beds
144
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1993-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 3 overall / 3 health / 3 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
RN hours / resident day
0.39
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
11,671
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.75
Performance 19.69% · Measure score 3.75 · Achievement 3.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0.52
Performance 7.68% · Measure score 0.52 · Achievement 0.52 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0.56
Baseline 56.52% · Performance 61.39% · Measure score 0.56 · Achievement 0.56 · Improvement 0
Adjusted total nurse staffing
1.46
Baseline 2.61 hours · Performance 3.23 hours · Measure score 1.46 · Achievement 0.54 · Improvement 1.46
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 6.04% |
| Discharge to community | 46.05% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 28.57% · Lower 95% interval 30.89% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 90.91% |
95.27%
4.4 pts worse
|
Numerator 40 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 6 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 1.41% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 12.77% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 1.96% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 102 |
| Staff flu vaccination coverage | 20.12% |
42%
21.9 pts worse
|
Numerator 34 · Denominator 169 |
| Discharge function score | 27.27% |
56.45%
29.2 pts worse
|
Numerator 6 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
91.2%
0.4 pts better
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 94.3% · Q3 87.8% · Q4 86.6% · 4Q avg 91.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.8% |
95.0%
11.2 pts worse
|
95.5%
11.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.2%
1.9 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 1.1% · Q4 2.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 71.4% |
9.6%
61.8 pts worse
|
11.4%
60 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.8% · Q2 72.0% · Q3 71.8% · Q4 70.3% · 4Q avg 71.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.9%
2.4 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 5.0% · Q3 2.4% · Q4 5.6% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
20.7%
11.7 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 9.9% · Q3 7.1% · Q4 6.7% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
21.4%
3.2 pts better
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.7% · Q3 23.1% · Q4 22.9% · 4Q avg 18.2% · 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 | 6.1% |
17.9%
11.8 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 19.2% · Q3 0.0% · Q4 2.2% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
16.2%
10.8 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.4% · Q3 5.3% · Q4 5.0% · 4Q avg 5.4% · 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 5.5% · Q2 1.1% · Q3 0.8% · Q4 0.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.5%
0.9 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.2% · Q3 1.1% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
16.1%
6.6 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 16.0% · Q3 26.1% · Q4 20.4% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.2%
1.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.2% · Q3 5.2% · Q4 7.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.5% |
80.4%
30.9 pts worse
|
81.7%
32.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 51.5% · Q3 44.7% · Q4 55.7% · 4Q avg 49.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.8% |
12.2%
10.4 pts better
|
12.0%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.8% · Observed 1.9% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.7% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.5% |
78.2%
39.7 pts worse
|
79.7%
41.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
24.2%
5.4 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 23.1% · Expected 29.3% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-02
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 2024-12-02
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 2024-12-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-20
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-20
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2024-06-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-20
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-06-20
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-06-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-20
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-20
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-29
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-29
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-29
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-09-29
Inspection history
Health
Provide and implement an infection prevention and control program.
Not marked corrected
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Not marked corrected
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Ensure medication error rates are not 5 percent or greater.
Not marked corrected
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.
Not marked corrected
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-08-29
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-29
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-29
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-02
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 2024-12-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-02
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 2024-12-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-02
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 2024-06-20
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-06-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-20
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 2024-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-20
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-20
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-06-20
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-23
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-23
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 2023-09-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-23
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-23
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-20
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-06-20
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-06-20
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-04-28
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-28
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-28
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-28
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-28
Penalties and ownership
Fine · fine $47,466
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
Tucker, GA
2-star overall rating with 2-star inspections with $30,000 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Stone Mountain, GA
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Tucker, GA
4-star overall rating with 4-star inspections with 3 recent health deficiencies
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