Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mesun Health And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to return a deceased resident's prepaid room and board funds in a timely manner after discharge. The resident, who had HF, early onset Alzheimer's disease, and severe cognitive impairment, had a large deposit made by the RP for hospice room and board, but repeated family requests showed the refund was still being processed well after discharge. The BOM and corporate financial staff acknowledged the refund had not yet been mailed, and the Administrator confirmed the facility's policy did not match the federal 30-day timeframe for returning resident funds.
The facility failed to thoroughly investigate two allegations involving a resident with severe cognitive impairment and another resident with intact cognition. One resident had no access to personal funds while the RP/rep payee did not respond to the facility, yet no internal investigation was initiated for potential financial abuse. For the other resident, a lower leg injury with bleeding during therapy was documented, but staff did not obtain a resident statement, and the DON acknowledged pertinent details may have been missed.
Failure to Monitor Psychotropic Medication Behaviors and Side Effects: The facility failed to ensure that psychotropic medications were monitored for target behaviors and side effects for two residents. One resident with Parkinson’s disease and schizophrenia received Haldol without orders or documentation for behavior or side-effect monitoring, and another resident with stroke history, depression, anxiety, insomnia, and vascular dementia with agitation received trazodone, Ativan, and Haldol without monitoring for side effects related to the antianxiety and antipsychotic medications. The DON confirmed the missing monitoring on the MAR/TAR.
Failure to timely report alleged financial abuse: A severely cognitively impaired resident with a history of stroke and Alzheimer's disease had no access to personal funds because the RP/Rep Payee family member did not respond to the facility's requests for payment or spending money. Staff, including the SSD and DON, believed the resident was being financially abused, but the allegation was not reported to the State Agency when first identified; the Administrator later acknowledged the report should have been made as soon as the facility became aware of the concern.
A resident with severe cognitive impairment and diagnoses including MS, prior TBI, and stroke was transferred to the hospital multiple times, but the facility did not provide a written transfer/discharge notice or bed hold policy to the resident or the resident’s representative. EMR review found no related forms, and staff interviews showed the LPN, SSD, and BOM were not following a process for issuing the required written notices, relying instead on courtesy phone calls.
Failure to Provide and Document Resident Activities: A resident with Parkinson's disease and schizophrenia had care plan interventions and activity preferences documented, including prayer, worship, family time, being outside, Christian music, and group activities. However, the activity participation log was blank, multiple observations showed the resident not engaged while activities were underway, and the AD confirmed there was no documentation of activity participation during the review period.
A resident with neurogenic bladder and severe cognitive impairment had a suprapubic catheter documented in the care plan and MDS, but the chart lacked a physician order for the actual catheter, including the size or type. The EMR contained orders for catheter maintenance and care, and the DON confirmed she could not locate an order for the catheter itself, despite facility policy requiring physician orders for indwelling catheter use.
Unnecessary Antibiotic Prescribed for UTI Without Clinical Criteria Met: A resident with dementia and metabolic encephalopathy was prescribed linezolid for a UTI after urine testing showed Enterococcus faecalis at 60,000 to 70,000 cfu/ml. The resident had no urinary symptoms, the McGeer UTI criteria were marked not met, and staff interviews showed the test was obtained because a family member requested it due to odd statements and confusion. The NP stated the resident should not have been on an antibiotic, while the MD said the treatment was based on the family’s request despite the resident having recently completed antibiotics in the hospital.
Medication Error Rate Exceeded Allowed Threshold: The facility failed to keep the medication error rate below 5%, with two errors found in 25 opportunities for error. One resident with atrial fibrillation and a history of stroke received enteric coated aspirin instead of ordered chewable aspirin, and another resident received a multivitamin without minerals instead of the ordered multivitamin with minerals. An LPN and an RN both confirmed the errors, and the DON stated medications were expected to be given according to physician orders.
The facility failed to properly store, label, and dispose of food items, affecting 47 residents on an oral diet. Observations revealed dented cans, unrefrigerated opened items, expired foods, and unlabeled opened packages. Staff interviews indicated a lack of oversight during the CDM's absence, leading to inconsistent adherence to food safety protocols.
The facility failed to implement an effective water management plan to prevent Legionella and other waterborne pathogens. Despite having policies in place, staff interviews revealed gaps in awareness and execution of preventive measures beyond annual testing. The Infection Prevention and Control Nurse and Maintenance Director were not fully informed of comprehensive strategies, leading to a deficiency in the infection prevention and control program.
The facility failed to transmit MDS assessments within regulatory guidelines for 31 residents due to staffing inconsistencies and unclear responsibilities. The MDS Coordinator could not submit assessments without an RN signature, and the DON was absent, leading to a backlog. The facility experienced turnover in the MDS RN Coordinator position, causing delays in submission.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident, omitting critical medications like an opioid and a diuretic. The resident had multiple diagnoses, including heart failure and chronic kidney disease, and was prescribed hydrocodone acetaminophen and furosemide. Interviews with staff revealed gaps in the care planning process, with the ADON and MDS LPN acknowledging the oversight and lack of documented interventions for managing high-risk medications.
A resident with moderate cognitive impairment and a primary language of Korean did not have her language preferences included in her care plan until months after admission. Staff used tools like a translator line and communication boards, but these were not documented in the care plan. The oversight was acknowledged by the ADON and Medical Director, highlighting the need for communication to be a focus in care plans.
Delayed Return of Resident Funds After Discharge
Penalty
Summary
The facility failed to ensure deposited monetary funds were returned timely after discharge for one resident, R88, out of 23 residents reviewed. R88 was admitted for hospice services with diagnoses including heart failure and early onset Alzheimer's disease, and the record indicated she was severely cognitively impaired. Family Member 1 was identified as the resident's responsible party, and R88 was discharged from the facility upon her death four days after admission. Financial records showed Family Member 1 paid a $9,750.00 deposit to cover room and board, while the resident's room and board charges for the brief stay totaled $1,300.00. Email correspondence documented repeated requests from Family Member 1 for the refund and multiple responses from the Business Office Manager and corporate financial staff indicating the refund was being worked on, had not yet been mailed, and would be sent later. The facility's refund policy stated approved refunds would be processed within 45 days, and the Administrator acknowledged that this did not reflect the federal 30-day timeframe for returning funds after discharge; he also confirmed the refund was not mailed until 32 days after discharge.
Failure to Thoroughly Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to protect residents from abuse by not conducting thorough investigations into two allegations involving Resident 5 and Resident 3. The facility policy required an immediate investigation of suspected abuse, including interviewing all involved persons, focusing on whether abuse, neglect, exploitation, or mistreatment occurred, and documenting the investigation completely. Resident 5 had a history of stroke and Alzheimer’s disease, a BIMS score of 3 out of 15 indicating severe cognitive impairment, and was represented by Family Member 3 as responsible party and rep payee. Financial records showed Family Member 3 did not respond to the facility’s attempts to contact her for payment or personal spending money for Resident 5, and Resident 5 had no access to his money since 10/2/2023. The facility’s internal investigation records showed no investigation was initiated regarding the potential financial abuse by Family Member 3, and the Administrator stated the potential abuse should have been investigated when the facility became aware of it. Resident 3 was admitted with diagnoses including paroxysmal atrial fibrillation, heart failure, and diabetes mellitus, and had a BIMS score of 14 out of 15 indicating intact cognition. During therapy in July 2025, Resident 3 had lower extremity bleeding after a reported injury to the lower left leg. The Director of Therapy stated the bleeding was from a bursting vessel and that she documented the event in a daily therapy note but did not write a statement. The DON stated the incident report served as the investigation and that CNA1 provided a statement, but there was no separate incident report or investigation for the ruptured hematoma during therapy on 7/29/2025. The DON also acknowledged that Resident 3 was not interviewed, and that pertinent details may have been missed. LPN2 stated CNA1 reported bumping Resident 3’s lower leg causing the hematoma, that Resident 3 complained of pain afterward, and that no statement from Resident 3 was obtained to her knowledge.
Failure to Monitor Psychotropic Medication Behaviors and Side Effects
Penalty
Summary
The facility failed to protect residents from abuse by ensuring chemical restraints were not used unless medically necessary for two residents reviewed for unnecessary medication. Surveyors found that the facility did not consistently monitor identified behaviors and potential side effects related to psychotropic medication administration for these residents, creating the potential for side effects related to unnecessary medication use. R16 was admitted with diagnoses including Parkinson’s disease and schizophrenia. Her care plan stated she was to receive her antipsychotic medication as ordered and that target behaviors and side effects were to be monitored each shift, but it did not identify specific behaviors to be monitored. Her quarterly MDS showed a BIMS score of 13, indicating she was cognitively intact, and that she had received antipsychotic medication and displayed no behaviors during the reference dates. Her order summary showed Haldol 5 mg by mouth at bedtime for schizophrenia, but there were no orders for tracking specified behaviors or potential side effects, and the MAR/TAR showed nothing indicating those behaviors or side effects were being monitored. R47 was admitted with diagnoses including history of stroke, depression, anxiety, insomnia, and vascular dementia with agitation, and he received hospice services. His care plan directed staff to administer psychotropic medications as ordered and to monitor for side effects and effectiveness every shift, including a detailed list of possible adverse reactions and behaviors associated with his depression, anxiety, and agitation. His quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and that he received antidepressant, antianxiety, and antipsychotic medications and displayed behaviors during the reference period. His order summary included trazodone, Ativan PRN for anxiety, Haldol PRN for agitation, and orders to monitor behaviors and side effects related to depression, but it did not include monitoring for side effects related to the antianxiety or antipsychotic medications, and the MAR/TAR showed nothing indicating those side effects were monitored. The DON confirmed that behaviors and side effects related to R16’s antipsychotic medication and R47’s antianxiety and antipsychotic medications were not monitored.
Failure to Timely Report Alleged Financial Abuse
Penalty
Summary
The facility failed to timely report an allegation of financial abuse involving one resident who was severely cognitively impaired, with a BIMS score of 3 out of 15 and diagnoses including a history of stroke and Alzheimer's disease. The resident's Responsible Party and Rep Payee was a family member who had not responded to the facility's attempts to contact her for payment of services or to provide the resident with personal spending money, and the resident had not had access to his money since 10/2/2023. Facility staff identified concerns that the resident was being financially abused by the Responsible Party, and the Social Services Director stated she reported those concerns to the previous Administrator in December 2023 and to APS, but the issue was not reported to the State Agency at that time. The DON confirmed the family member remained the Rep Payee and that the resident was being taken advantage of financially, while the Administrator later stated he was aware of the concerns, had reported them to APS and the local Police Department, and acknowledged that the potential financial abuse should have been reported to the State Agency as soon as the facility became aware of it.
Failure to Provide Written Transfer Notice and Bed Hold Information
Penalty
Summary
The facility failed to ensure that Resident 55 and the resident’s representative received a written bed hold policy and transfer notice related to hospital transfers. Record review showed Resident 55 was admitted to the facility on [DATE] and had been transferred to the hospital four times in the past ten months. The resident’s quarterly MDS with an ARD of 7/15/2025 showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The resident’s diagnoses included multiple sclerosis, personal history of traumatic brain injury, and cerebral infarct (stroke). Review of the resident’s EMR Misc tab showed no bed hold or notice of transfer forms related to the hospitalizations. During interviews, an LPN stated she had never filled out a transfer/discharge notice and was not aware one needed to be completed and provided to residents and their representatives. The Administrator stated the SSD was responsible for providing the transfer notice and bed hold policy, while the SSD stated she did not provide residents or their representatives with a written transfer/discharge notice or bed hold information and was not the person responsible for that task. The BOM stated the facility did not send bed hold policies or written transfer notices because they made a courtesy phone call to the resident representative at the time of transfer to the hospital.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to ensure a consistent program of activities was provided and documented for one resident, R16, who was reviewed for activities. The resident had diagnoses of Parkinson's disease and schizophrenia, and the care plan stated the resident was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits and immobility. The care plan interventions included offering activities compatible with the resident's abilities and preferences, introducing the resident to others with similar interests, inviting the resident to scheduled activities, and providing assistance or escort to activity functions. R16's activities assessment indicated preferences for praying and worshiping, spending time with family, being outside, listening to Christian music, and participating in group activities, outings, one-to-one visits, and independent activities, with staff assistance needed to get to activities. However, the resident's activity participation log from 10/19/2025 through 11/21/2025 was blank and showed no documentation of any activity attendance. During multiple observations, R16 was seen in the room or seated in front of the nurses' station while group activities were occurring, without engagement with other residents or staff or participation in any activity. The Activities Director confirmed R16 had not been in activities much that week, that participation should be documented in each resident's log, and that there was no documentation showing R16 had participated in any activities since 10/19/2025.
Missing Physician Order for Suprapubic Catheter
Penalty
Summary
The facility failed to ensure physician orders were in place for one resident’s suprapubic urinary catheter. The resident was admitted with a diagnosis of neurogenic bladder and had a suprapubic catheter documented in the care plan as being in place in the bladder. The resident’s MDS indicated an internal urinary catheter was present and that the resident had a BIMS score of 7 out of 15, showing severe cognitive impairment. Review of the physician order report showed orders for maintenance and care of the suprapubic catheter, but no order for the actual catheter itself, including the size or type of indwelling catheter. The facility’s policy stated that use of an indwelling urinary catheter must be in accordance with physician’s orders, including the diagnosis or clinical condition, catheter size, and frequency of change if applicable. During interview, the DON confirmed she could not locate an order for the resident’s suprapubic catheter and stated her expectation that an order for the actual catheter size and type should be in place.
Unnecessary Antibiotic Prescribed for UTI Without Clinical Criteria Met
Penalty
Summary
The facility failed to ensure clinical criteria were met before prescribing and administering an antibiotic for a urinary tract infection for one resident. The resident had an admission date of 11/7/2025, a BIMS score of 9 out of 15, and diagnoses including metabolic encephalopathy, non-Alzheimer's dementia, and UTI. A urine culture dated 11/17/2025 showed Enterococcus faecalis with a colony count of 60,000 to 70,000 cfu/ml, and on 11/18/2025 the resident was ordered linezolid 600 mg by mouth every 12 hours for UTI for 7 days. The resident's record included a Revised McGeer Criteria for Infection Surveillance Checklist dated 11/20/2025 with a large X over both sections for UTI without an indwelling catheter, indicating the UTI criteria were not met. During observation and interview, the resident was seated in a wheelchair with a family member present; the family member stated the resident had just completed an antibiotic for a UTI in the hospital before admission and had a change in demeanor but no urinary symptoms such as burning or frequency. The resident stated he felt fine. Staff interviews showed the urine testing was done because the family member asked the NP to have it completed due to odd statements the resident made. The IP initially stated the urine analysis and culture qualified as a UTI and that an antibiotic was prescribed based on McGeer criteria and the organism growth, but later stated the resident did not meet McGeer criteria because he was not symptomatic and the culture did not meet the indicated level. The NP stated the resident should not have been on an antibiotic, and MD1 stated the family wanted to try an antibiotic because the resident was acting confused and that the decision was based on the family's request despite awareness that the resident had just completed a round of antibiotics in the hospital.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. Based on record review, observations, staff interviews, and facility policy review, two medication errors were identified during administration for two of seven residents observed, resulting in an eight percent medication error rate. The facility’s Medication Administration Policy, dated April 2025, required the six rights of medication administration, including the right drug and right dosage. One resident had diagnoses of atrial fibrillation and a history of stroke and was ordered aspirin 81 mg chewable by mouth daily. During observation, the resident received enteric coated aspirin instead of the ordered chewable aspirin. The LPN confirmed she had given enteric coated aspirin and stated she usually administered that form even though both chewable and enteric coated aspirin were available in the medication cart. A second resident with diagnoses including history of pancreatic cancer, acute kidney failure, and morbid obesity was ordered multivitamin with minerals one tablet by mouth daily. During observation, the resident received a multivitamin without minerals instead of the ordered multivitamin with minerals. The RN confirmed the error and stated the ordered multivitamin with minerals was not available in the medication cart, but she should have given the medication according to the physician’s order. The DON stated her expectation was for medications to be administered according to physician’s orders.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of food items, which could potentially affect 47 of 49 residents consuming an oral diet. Observations revealed several issues, including a large dented can of corn, and multiple items in the pantry that were not refrigerated after opening, such as soy sauce, grape jelly, Italian dressing, and barbecue sauce. Additionally, expired foods like a bag of long grain rice and seven bags of marshmallows were found, along with numerous opened food packages without labels displaying the date they were opened. The freezer contained food items with frostbite, such as meat and fish, which also lacked open dates. Interviews with staff highlighted a lack of oversight and adherence to food safety protocols. The Certified Dietary Manager (CDM) was on vacation, and there was confusion about who was in charge in her absence. Staff confirmed that open containers should be labeled with open dates and that dented cans should not be used, yet these practices were not consistently followed. The Registered Dietitian Consultant noted that during her last kitchen observation, items were dated and the kitchen was clean, but she was unaware of the CDM's absence until her arrival at the facility.
Deficiency in Water Management Plan for Infection Control
Penalty
Summary
The facility failed to develop an effective water management plan to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens throughout its water system. The facility's policies, titled Infection Prevention and Control Program and Water Management, were reviewed and found lacking in routine water management activities. The policies indicated that control measures and testing protocols should be in place to address potential hazards associated with the facility's water system. However, the facility's water management team did not regularly verify the implementation of the water management program as designed, nor did they evaluate its effectiveness at least annually using routine infection control surveillance data, water quality data, and rounding data. Interviews with facility staff revealed gaps in the implementation of the water management plan. The Infection Prevention and Control Nurse stated that the facility had policies and procedures in place to prevent the spread of Legionella, but the Administrator was only aware of annual testing and not of other preventive measures. The Maintenance Director confirmed performing daily temperature checks and annual testing for Legionella but was unaware of additional measures to prevent the growth of water-borne pathogens. This lack of awareness and implementation of comprehensive preventive measures contributed to the deficiency in the facility's infection prevention and control program.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that required Minimum Data Set (MDS) assessments were transmitted within regulatory guidelines to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for 31 residents out of 44 sampled residents. The facility's policy required that all MDS assessment files be transmitted within 14 days of the completion date. However, several assessments were either coded as 'export ready' but not submitted or were still 'in progress' despite being more than 120 days old. This issue was identified through a review of the facility's policy, staff interviews, and record reviews. The deficiency was attributed to a lack of consistent staffing and clear responsibility for the submission of MDS assessments. The MDS Coordinator indicated that assessments could not be submitted without a Registered Nurse (RN) signature, and the current Director of Nursing (DON) was responsible for signing them. However, the DON had been absent for an extended period, and there was no one else assigned to sign off on the assessments. The facility had experienced turnover in the MDS RN Coordinator position, with four different coordinators in the past year, leading to a backlog of unsubmitted assessments. Interviews with the Administrator and Assistant Director of Nursing (ADON) revealed confusion over who was responsible for submitting the assessments, contributing to the delay in submission.
Failure to Develop Baseline Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which included addressing two critical medications: an opioid and a diuretic. This oversight was identified during a review of the facility's policy on baseline care plans, which mandates that such plans be developed within 48 hours of a resident's admission and include necessary healthcare information such as physician orders and interventions for high-risk medications. The resident in question had multiple diagnoses, including heart failure and chronic kidney disease, and was prescribed hydrocodone acetaminophen and furosemide. However, the baseline care plan did not document these medications, leaving staff without guidance on managing potential side effects or necessary interventions. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Licensed Practical Nurse (LPN), revealed gaps in the care planning process. The ADON confirmed that high-risk medications should be monitored and included in the care plan, but acknowledged a lack of awareness on how these items were care planned. The MDS LPN admitted to not having completed the baseline care plan for the resident, despite being familiar with the case. This deficiency in care planning could potentially lead to adverse medical effects for the resident, as there were no documented interventions for staff to follow.
Failure to Include Language Preferences in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that included communication or language preferences for a resident whose primary language was not English. The resident, identified as R179, was admitted with diagnoses including Covid-19, presence of a cardiac pacemaker, hypothyroidism, and generalized muscle weakness. The Admission Minimum Data Set (MDS) assessment indicated her preferred language was Korean, and she had moderate cognitive impairment. Despite this, the care plan did not address her language needs until several months after her admission, which could adversely impact her quality of care and life. Interviews with facility staff revealed that the MDS Licensed Practical Nurse (LPN) was self-taught and the only MDS nurse on staff, confirming the oversight in the care plan. The staff used various tools like a translator telephone line and communication boards to communicate with non-English-speaking residents, but these were not documented in the care plan for R179. The Assistant Director of Nursing (ADON) and the Medical Director acknowledged the omission and agreed that including communication as a focus concern in the care plan would be beneficial for addressing potential challenges related to language, cognition, or diagnosis.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 260 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lawrenceville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Ctr Of Lawrenceville | 3.6 mi | ★★★★★ | 6 | 0 |
| Cambridge Post Acute Care Center | 7.2 mi | ★★★★★ | 10 | 0 |
| Parkside Post Acute And Rehabilitation | 7.6 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens Of Gwinnett | 7.9 mi | ★★★★★ | 4 | 0 |
| Salude - The Art Of Recovery | 8.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mesun Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.