Cycle 1
Health 2025-05-01 · Fire 2025-05-01
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Stone Mountain, GA
Pebblebrook Health Center At Park Springs
4-star overall rating with 3-star inspections with $19,408 in total fines with 6 recent health deficiencies
5610 New Bermuda Road, Stone Mountain, GA
(678) 684-3157
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-05-27
CMS approved date
Coverage
Medicare
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
0.93
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
3.44
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.28
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
5.03
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.76
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
0.97
CMS adjusted RN staffing hours
Adjusted total hours
5.46
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,522
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0111
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.38
Baseline 20.42% · Performance 19.40% · Measure score 4.38 · Achievement 4.38 · Improvement 2.50
Healthcare-associated infections
5.74
Baseline 7.81% · Performance 6.12% · Measure score 5.74 · Achievement 5.74 · Improvement 5.52
Total nurse turnover
4.24
Performance 46.34% · Measure score 4.24 · Achievement 4.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.04
Performance 5.36 hours · Measure score 8.04 · Achievement 8.04 · 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 | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 4.35% · Lower 95% interval 6.26% |
| Discharge to community | 34.35% |
50.57%
16.2 pts worse
|
Worse than the National Rate · Eligible stays 67 · Observed rate 26.87% · Lower 95% interval 24.71% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 3.77% |
0.77%
3 pts worse
|
Numerator 2 · Denominator 53 |
| Discharge self-care score | 52.5% |
53.69%
1.2 pts worse
|
Numerator 21 · Denominator 40 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 18 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 1.92% · Lower 95% interval 3.24% |
| Staff COVID-19 vaccination coverage | 2.99% |
8.2%
5.2 pts worse
|
Numerator 2 · Denominator 67 |
| Staff flu vaccination coverage | 27.78% |
42%
14.2 pts worse
|
Numerator 30 · Denominator 108 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 22 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 78.57% |
25.2%
53.4 pts better
|
Numerator 22 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
91.2%
3.8 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 92.6% · Q3 96.0% · Q4 100.0% · 4Q avg 95.0% |
| 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 | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 | 7.4% |
5.9%
1.5 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
20.7%
12.4 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
21.4%
2.7 pts worse
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · 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 need for help with daily activities has increased | 33.3% |
16.2%
17.1 pts worse
|
14.9%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
2.5%
2.7 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 0.0% · Q4 13.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
16.1%
15.8 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.3% · Q2 29.4% · Q3 40.3% · Q4 13.8% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.2%
1.4 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.5% · Q3 3.0% · Q4 5.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
80.4%
5.4 pts better
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 88.2% · Q3 82.1% · Q4 81.8% · 4Q avg 85.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
12.2%
7.9 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 3.9% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.3% |
78.2%
7.1 pts better
|
79.7%
5.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
24.2%
1.2 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 19.6% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-17 · Fire 2022-07-17
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-08
F · Potential for more than minimal harm
2022-07-17
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-17
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-17
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2022-09-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-01
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 2025-06-15
F · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-15
E · Potential for more than minimal harm
2025-05-01
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 2025-06-15
D · Potential for more than minimal harm
2025-05-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-01
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 2025-06-15
D · Potential for more than minimal harm
2025-05-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-15
E · Potential for more than minimal harm
2023-11-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-08
F · Potential for more than minimal harm
2022-07-17
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 2022-08-30
D · Potential for more than minimal harm
2022-07-17
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-08-30
Penalties and ownership
What sits behind the stars
$4,587
2023-08-14
Fine
Fine · fine $4,587
Fine
$4,235
2023-08-07
Fine
Fine · fine $4,235
Fine
$10,586
2023-07-17
Fine
Fine · fine $10,586
Fine
Ownership
Berger, Mark
Operational/Managerial Control · Individual
Godwin, Melody
Operational/Managerial Control · Individual
Helms, Jeffrey
Operational/Managerial Control · Individual
Isakson Living, Inc.
Operational/Managerial Control · Organization
Isakson, Kevin
Corporate Officer · Individual
Khan, Khurram
Operational/Managerial Control · Individual
Levato, Amanda
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Security Interest · Organization
Truist Bank
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Stone Mountain Run Of Journey LLC
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
#2
Tucker Operating Company LLC
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
#3
Meadowbrook Health And Rehab
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
Jump out