Willowbrooke Court at Lanier Village Estates
Gainesville, Georgia · CCN 115687
8 surveys since 2011, 13 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 44
- Surveys
- 8
- Harm or worse
- 13
- Immediate jeopardy
- 13
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 48
- Ownership
- Non profit - Corporation
- Chain
- ACTS RETIREMENT-LIFE COMMUNITIES
- County
- Hall
- Medicare-certified since
- 2003
CMS ratings
- Overall
- 5
- Health inspection
- 5
- Staffing
- 5
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=11, floor 20).
Last survey on record
Sep 21, 2025
414 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.24 | 3.81 |
| Registered-nurse hours per resident day | 0.69 | — |
| Annual nurse turnover | 23.1% | 43.9% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D787.5% | E112.5% | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
From the most serious findings on record at Willowbrooke Court at Lanier Village Estates, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF812Jun 24, 2021
Based on observations, staff interviews, and policies Operational Standards Storeroom and Date Marking Ready-to-Eat Foods reviewed, the facility failed to discard expired food items in the freezer, label and date items in the main kitchen pantry, label and date items in the resident's pantry, and keep the ice machine clean. These deficient practices had the potential to affect 58 of 59 residents receiving an oral diet. Findings include: Review of Operational Standards Storeroom policy, dated ,d+[DATE], revised ,d+[DATE] revealed procedure is all items are organized for easy inventory, foods are stored properly, ensuring opened containers are properly sealed and labeled with the date of opening and the use-by date (month, day and year), all foods are stored in the delivery box with the… […]
- No harm, potential for more than minimal, patternF813Feb 12, 2023
Based on observation, interviews, and review of facility policy titled, Personal Food in Willowbrooke Court the facility failed to ensure that a policy regarding resident personal food included procedure for safe consumption/safe reheating to prevent food borne illness. The deficient practice had the potential to affect 60 of 60 residents receiving an oral diet. Findings include: Review of the fcility policy titled, Personal Food in Willowbrooke Court dated 2/2017 revealed directions for food storage. The policy had no guidelines regarding safe consumption of hot foods if re-heated. Interview on 2/11/2023 at 11:45 a.m. with the Director of Dietary Services (DDS) revealed that he was not sure about a policy that included safe consumption or reheating of food items bought in from outside. […]
- No harm, potential for more than minimal, patternF700Jun 24, 2021
Based on record review, observations, staff interviews and review of the facility policy titled Side Rail/Bed Rail Usage, the facility failed to assess for the risk of entrapment from bed rails, for two residents (R) (#48) and (R#4); and failed to obtain informed consent, Physician Orders and attempt alternative methods for 36 of 39 residents prior to the use of assist rails (R#1, R#2, R#6, R#7, R#8, R#10, R#12, R#13, R#15, R#16, R#17, R#19, R#20, R#22, R#23, R#25, R#26, R#27, R#28, R#29, R#30, R#33, R#37, R#38, R#40, R#41, R#43, R#45, R#46, R#51, R#52, R#57, R#58, R#59, R#610, and R#613). […]
- No harm, potential for more than minimal, isolatedF880Sep 21, 2025
Based on observations, staff interviews, and review of the facility policy titled, Guidelines for Isolation Precautions, the facility failed to follow Enhanced Barrier Precautions (EBP) for two of four residents (R) (R6 and R8) on EBP while providing high-contact care. This deficient practice had the potential to increase the spread of infection due to cross-contamination.Findings include: A review of the facility policy, Guideline for Isolation Precautions revised 3/23/2023, revealed staff were required to use Enhanced Barrier Precautions (EBP), which included wearing gowns and gloves when performing high-contact care activities. […]
- No harm, potential for more than minimal, isolatedF655Apr 28, 2024
Based on observations, staff interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to implement interventions for oxygen therapy for one of seven residents (R) (R290) receiving oxygen therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Baseline Care Plan, last review date of 5/2018 under Policy revealed, To strive to initiate a baseline care plan for a resident based upon the medical plan and nursing assessment, which includes the instructions needed to provide person-centered care and meets the professional stands of quality care. […]
Read 33 findings in full →The most serious and the most recent: 33 of 44 on record.
Every survey on record
FindingsAt actual harm or above
- Sep 21, 2025Standard1 finding
- Apr 28, 2024Standard4 findings
- Feb 12, 2023Standard3 findings
- Jun 24, 2021Standard3 findings
- Sep 16, 2018Standard4 findings
- Jun 9, 2016Standard and complaint2 findings
- Feb 29, 2012—4 findings
- Feb 4, 2011Standard23 findings · 13 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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