Cycle 1
Health 2025-11-21 · Fire 2025-11-21
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lawrenceville, GA
Mesun Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $4,017 in total fines with 9 recent health deficiencies
88 Johnson Road, Building #2, Lawrenceville, GA
(404) 367-1907
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2021-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.79
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.82
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
3.99
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.57
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
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,837
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.88
Baseline 18.00% · Performance 20.56% · Measure score 1.88 · Achievement 1.88 · Improvement 0
Healthcare-associated infections
2.53
Baseline 6.98% · Performance 7.08% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Total nurse turnover
1.09
Performance 59.21% · Measure score 1.09 · Achievement 1.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.51
Performance 3.22 hours · Measure score 0.51 · Achievement 0.51 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.26% |
10.72%
2.5 pts worse
|
Worse than the National Rate · Eligible stays 444 · Observed rate 13.74% · Lower 95% interval 11.13% |
| Discharge to community | 57.05% |
50.57%
6.5 pts better
|
Better than the National Rate · Eligible stays 444 · Observed rate 50.23% · Lower 95% interval 52.84% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 60.15% |
95.27%
35.1 pts worse
|
Numerator 157 · Denominator 261 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 261 |
| Discharge self-care score | 40.41% |
53.69%
13.3 pts worse
|
Numerator 78 · Denominator 193 |
| Discharge mobility score | 30.05% |
50.94%
20.9 pts worse
|
Numerator 58 · Denominator 193 |
| Pressure ulcers or injuries, new or worsened | 3.83% |
2.29%
1.5 pts worse
|
Numerator 10 · Denominator 261 · Adjusted rate 3.89% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 242 · Observed rate 7.44% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 3.25% |
8.2%
4.9 pts worse
|
Numerator 4 · Denominator 123 |
| Staff flu vaccination coverage | 65.41% |
42%
23.4 pts better
|
Numerator 104 · Denominator 159 |
| Discharge function score | 41.97% |
56.45%
14.5 pts worse
|
Numerator 81 · Denominator 193 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | 98.88% |
96.28%
2.6 pts better
|
Numerator 177 · Denominator 179 |
| Resident COVID-19 vaccinations up to date | 30.97% |
25.2%
5.8 pts better
|
Numerator 48 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
95.0%
2.4 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.2%
2.3 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
9.6%
7.1 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 4.8% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.9%
2.7 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
20.7%
8 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.3% |
21.4%
7.9 pts worse
|
16.7%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.9% |
0.1%
0.8 pts worse
|
0.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.4% |
16.2%
18.2 pts worse
|
14.9%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.4% · 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 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.5%
1.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · 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 40.4% · Q2 36.3% · Q3 16.6% · Q4 26.7% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
6.2%
2.9 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 15.0% · Q3 8.1% · Q4 3.2% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
80.4%
13.6 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 96.0% · Q3 93.8% · Q4 91.0% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
12.2%
0.6 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.2%
1.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
78.2%
17.6 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
24.2%
5 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 29.8% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2024-07-18
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-05-25 · Fire 2022-05-25
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-30
F · Potential for more than minimal harm
2024-07-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-18
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-18
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 2024-08-30
D · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-30
F · Potential for more than minimal harm
2022-05-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-07-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
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 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-26
F · Potential for more than minimal harm
2024-07-18
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 2024-09-17
F · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-07-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-07-18
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-07-18
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 2024-09-17
D · Potential for more than minimal harm
2023-12-06
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 2024-01-19
D · Potential for more than minimal harm
2023-12-06
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 2024-01-19
F · Potential for more than minimal harm
2022-05-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-05-25
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-05-25
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-05-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-05-25
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 2022-07-29
E · Potential for more than minimal harm
2022-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-05-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-05-25
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-25
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 2022-07-29
D · Potential for more than minimal harm
2022-05-25
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-25
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 2022-07-29
D · Potential for more than minimal harm
2022-05-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-05-25
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-07-29
Penalties and ownership
What sits behind the stars
$4,017
2024-07-18
Fine
Fine · fine $4,017
Fine
$0
2024-07-18
Payment Denial
Payment Denial · denial start 2024-10-16 · 2 days
2 day denial
Ownership
Cotton, Danny
Corporate Officer · Individual
Cotton, Danny
W-2 Managing Employee · Individual
Kim, Eugene
5% Or Greater Direct Ownership Interest · Individual
Kim, Hanson
5% Or Greater Direct Ownership Interest · Individual
Kim, Hanson
Corporate Officer · Individual
Radman, Bruce
Operational/Managerial Control · Individual
Radman, Bruce
W-2 Managing Employee · Individual
Seol, Sukhee
Corporate Officer · Individual
Seol, Sukhee
W-2 Managing Employee · Individual
Nearby options
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#2
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1-star overall rating with 2-star inspections with $24,162 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Parkside Post Acute And Rehabilitation
Snellville, GA
1-star overall rating with 2-star inspections with $8,512 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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