Cycle 1
Health 2025-04-24 · Fire 2025-04-24
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Atlanta, GA
Terraces At Peachtree Hills Place, The
5-star overall rating with 4-star inspections with 4 recent health deficiencies
229 Peachtree Hills Avenue, Ne, Atlanta, GA
(678) 619-5600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
25
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2021-02-25
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
1.20
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.55
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
2.29
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
5.24
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
5.47
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,712
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0094
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.64
Baseline 22.97% · Performance 18.73% · Measure score 6.64 · Achievement 5.84 · Improvement 6.64
Healthcare-associated infections
5.08
Baseline 9.67% · Performance 7.06% · Measure score 5.08 · Achievement 2.58 · Improvement 5.08
Total nurse turnover
4.65
Baseline 76.67% · Performance 50.00% · Measure score 4.65 · Achievement 3.35 · Improvement 4.65
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 173 · Observed rate 8.09% · Lower 95% interval 7.71% |
| Discharge to community | 61.95% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 186 · Observed rate 59.14% · Lower 95% interval 53.93% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.03% |
95.27%
3.8 pts better
|
Numerator 102 · Denominator 103 |
| Falls with major injury | 2.91% |
0.77%
2.1 pts worse
|
Numerator 3 · Denominator 103 |
| Discharge self-care score | 51.81% |
53.69%
1.9 pts worse
|
Numerator 43 · Denominator 83 |
| Discharge mobility score | 44.58% |
50.94%
6.4 pts worse
|
Numerator 37 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 1.94% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 103 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 6.87% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 58 |
| Staff flu vaccination coverage | 54.72% |
42%
12.7 pts better
|
Numerator 29 · Denominator 53 |
| Discharge function score | 53.01% |
56.45%
3.4 pts worse
|
Numerator 44 · Denominator 83 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 87.5% |
96.28%
8.8 pts worse
|
Numerator 63 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 51.06% |
25.2%
25.9 pts better
|
Numerator 24 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
91.2%
7.9 pts worse
|
93.4%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 83.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.1% |
3.2%
7.9 pts worse
|
3.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
9.6%
5.6 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.9%
2.4 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
20.7%
9.2 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
21.4%
10.3 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 43.8% |
16.2%
27.6 pts worse
|
14.9%
28.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 43.8% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
2.5%
3.5 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.4% |
16.1%
3.7 pts better
|
19.8%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.4% |
| Percentage of long-stay residents with pressure ulcers | 14.3% |
6.2%
8.1 pts worse
|
5.1%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
80.4%
9.9 pts better
|
81.7%
8.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 90.7% · Q3 87.5% · Q4 80.6% · 4Q avg 90.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
12.2%
2 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
2.2%
1 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.1% |
78.2%
12.1 pts worse
|
79.7%
13.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
24.2%
3.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 19.5% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-03 · Fire 2023-12-03
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-10-23 · Fire 2022-10-23
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-03
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 2024-01-17
F · Potential for more than minimal harm
2023-12-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-03
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-17
F · Potential for more than minimal harm
2022-10-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-24
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 2025-06-06
E · Potential for more than minimal harm
2025-04-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-24
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 2025-06-06
D · Potential for more than minimal harm
2023-12-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-17
Penalties and ownership
What sits behind the stars
Ownership
Berger, Mark
Operational/Managerial Control · Individual
Daugherty, Angela
Operational/Managerial Control · Individual
Heath, Gregory
Corporate Officer · Individual
Isakson Living, Inc.
Operational/Managerial Control · Organization
Isakson, Edwin
Corporate Officer · Individual
Isakson, Kevin
Corporate Officer · Individual
Keppen, Theresa
Operational/Managerial Control · Individual
Khan, Khurram
Operational/Managerial Control · Individual
Wahn, David
Corporate Officer · Individual
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#2
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#3
Parkside At Budd Terrace Operating Company LLC
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4-star overall rating with 3-star inspections with 7 recent health deficiencies
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