Inspection Report Summary
The most recent inspection on March 5, 2025, found that all previously cited deficiencies were corrected and no new deficiencies were noted. Earlier inspections, including the January 19, 2025 survey, identified deficiencies related mainly to pharmacy management—specifically the lack of required 14-day stop dates on psychotropic medications—and medical and nursing care, such as inaccessible call lights and infection control issues with respiratory equipment. Complaint investigations in recent years were mostly unsubstantiated, with one substantiated finding in 2019 involving failure to report an abuse allegation and lack of a designated registered nurse as Director of Nursing. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent surveys confirming correction of prior deficiencies and compliance with key regulations.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
49 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility Lenbrook, indicating regulatory oversight and corrective actions following an inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Follow-Up
Census: 49
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
A health revisit survey was conducted at Lenbrook-LTC on March 5, 2025 to verify correction of deficiencies cited in the Recertification survey and Complaint Investigation survey that concluded on January 19, 2025.
Findings
All deficiencies cited as a result of the Recertification survey in conjunction with a Complaint Investigation survey were found to be corrected.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 19, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Lenbrook-LTC from January 17, 2025 through January 19, 2025 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in pharmacy management for failing to implement a 14-day stop date on psychotropic medications for two residents, and in medical and nursing care for failing to ensure one resident's call light was accessible, posing safety risks.
Deficiencies (2)
Failure to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for two residents (R7 and R21).
Failure to ensure one resident's (R9) call light was accessible to meet care needs, safety, and fall prevention.
Report Facts
Residents reviewed for unnecessary medications: 5
Sampled residents for call light accessibility: 21
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Interviewed and confirmed no 14-day stop date for R21's lorazepam, stating it was an oversight. | |
| Director of Nursing (DON) | Interviewed and acknowledged no 14-day stop date on R21's and R7's lorazepam, stating it was an oversight; also stated all call lights must be within easy reach of residents. | |
| Certified Nursing Assistant (CNA) DD | Observed R9's inaccessible call light and sought assistance. | |
| Certified Nursing Assistant (CNA) EE | Assisted in moving R9's recliner closer to the call light. |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 3
Date: Jan 19, 2025
Visit Reason
A standard annual survey was conducted at Lenbrook LTC from January 17, 2025, through January 19, 2025, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccessible call lights for residents, failure to prevent infection spread due to improper handling of respiratory equipment, and lack of required stop dates on psychotropic medication orders.
Deficiencies (3)
Failed to ensure one of 21 sampled residents' call light was accessible to meet care needs, safety, and fall prevention.
Failed to prevent the spread of infections by not replacing or cleaning a nasal cannula for one of five residents requiring oxygen therapy.
Failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for two of five residents reviewed for unnecessary medications.
Report Facts
Residents present: 54
Sampled residents: 21
Residents reviewed for psychotropic medications: 5
Residents with psychotropic medication deficiencies: 2
Residents requiring oxygen therapy: 5
Residents with nasal cannula infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA DD | Certified Nursing Assistant | Mentioned in call light accessibility deficiency and resident assistance |
| CNA EE | Certified Nursing Assistant | Assisted in repositioning resident's recliner for call light accessibility |
| CNA JJ | Certified Nursing Assistant | Failed to replace contaminated nasal cannula immediately |
| LPN II | Licensed Practical Nurse | Replaced contaminated nasal cannula and reminded CNA JJ of infection control protocols |
| LPN AA | Licensed Practical Nurse | Audited charts for psychotropic medication stop dates and confirmed oversight |
| Director of Nursing | Director of Nursing | Provided statements on call light accessibility, respiratory equipment protocols, and psychotropic medication stop date expectations |
Inspection Report
Life Safety
Census: 54
Capacity: 60
Deficiencies: 0
Date: Jan 18, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Plan was found in compliance with 42 CFR &483.73.
Report Facts
Stories: 3
Construction Type: 2
Certified Beds: 60
Census: 54
Inspection Report
Routine
Deficiencies: 2
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess compliance with respiratory care infection control protocols and psychotropic medication use policies in the facility.
Findings
The facility failed to prevent infection spread by not replacing or cleaning a nasal cannula that fell on the floor for one resident requiring oxygen therapy, and failed to ensure a 14-day stop date was implemented for psychotropic medications for two residents, resulting in potential risks for infection and unnecessary medication use.
Deficiencies (2)
Failure to prevent the spread of infections by not replacing or cleaning a nasal cannula for a resident requiring oxygen therapy.
Failure to ensure a 14-day stop date was implemented for psychotropic medications for two residents.
Report Facts
Residents affected: 1
Residents affected: 2
Medication administration dates: 10
Medication administration dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Certified Nursing Assistant | Named in respiratory care deficiency for not replacing nasal cannula immediately |
| HH | Certified Nursing Assistant | Observed and reminded CNA JJ about infection control protocol |
| II | Licensed Practical Nurse | Replaced nasal cannula and reminded CNA JJ of infection control protocols |
| AA | Licensed Practical Nurse | Audited charts and confirmed no 14-day stop date for psychotropic medications |
| Director of Nursing | Director of Nursing | Provided expectations on respiratory equipment and psychotropic medication stop dates |
Inspection Report
Abbreviated Survey
Census: 54
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00251057.
Complaint Details
Complaint Intake Number GA00251057 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: May 28, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 28, 2024
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility Lenbrook located in Atlanta, GA.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are unknown.
Inspection Report
Life Safety
Census: 53
Capacity: 60
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).
Report Facts
Certified Beds: 60
Census: 53
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
A State Licensure survey was conducted from 8/15/2023 through 8/17/2023 to determine compliance with State Long Term Care Requirements.
Findings
No deficiencies were cited during the survey.
Inspection Report
Routine
Census: 54
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
A standard survey was conducted at Lenbrook from August 15, 2023 through August 17, 2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
A standard survey was conducted at Lenbrook from March 22, 2022 through March 24, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
The inspection was conducted as a licensure survey from March 22, 2022 through March 24, 2022.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the nursing home Lenbrook, summarizing the results of a survey completed on 2022-03-24.
Findings
No health deficiencies were found during the survey.
Inspection Report
Life Safety
Census: 51
Capacity: 60
Deficiencies: 0
Date: Mar 22, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Stories: 2
Stories: 4
Construction Type: 332
Inspection Report
Abbreviated Survey
Census: 53
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal infection control regulations and emergency preparedness requirements related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including implementation of CMS and CDC recommended practices to prevent COVID-19.
Report Facts
Total census: 53
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00202380.
Complaint Details
Complaint #GA00202380 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
The visit was conducted to assess the facility's infection control practices related to COVID-19 and to investigate complaint GA00204318.
Complaint Details
Complaint GA00204318 was investigated and found to be not substantiated.
Findings
No regulatory violations were cited and the allegation was not substantiated following observations and interviews during the COVID-19 Focused Infection Control Survey.
Inspection Report
Routine
Census: 43
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 25, 2019
Visit Reason
A follow-up to the Complaint survey of August 27, 2019, was conducted to verify correction of previous deficiencies.
Complaint Details
The visit was a follow-up to a complaint survey conducted on August 27, 2019. All deficiencies identified previously were corrected.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 18, 2019.
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 2
Date: Aug 27, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was initiated to investigate allegations of abuse at the facility.
Complaint Details
The visit was complaint-related, investigating allegations of abuse involving resident #5. The allegation was substantiated as the facility failed to report the abuse allegation to the State Survey Office as required.
Findings
The facility failed to report an allegation of abuse involving one resident to the State Survey Office in a timely manner. Additionally, the facility did not have a registered nurse designated as Director of Nursing from 3/8/19 through 8/12/19, which posed potential risk to residents.
Deficiencies (2)
Failure to report an allegation of abuse to the State Survey Office within required timeframes.
Failure to designate a registered nurse as Director of Nursing from 3/8/19 through 8/12/19.
Report Facts
Facility census: 55
Residents reviewed for abuse: 6
Dates RN not designated as DON: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Received call about abuse allegation and documented related events. |
| RN EE | Registered Nurse | Interviewed regarding abuse allegation and facility DON status. |
| Administrator | Facility Administrator interviewed multiple times regarding abuse reporting and DON designation. | |
| Compliance Officer | Responsible for reporting abuse allegations; failed to report one allegation. | |
| ADON | Assistant Director of Nursing | Interviewed regarding DON designation and abuse reporting. |
| HR Director | Human Resources Director | Interviewed regarding DON designation and reporting procedures. |
| CEO | Chief Executive Officer | Interviewed regarding expectations for abuse reporting. |
Inspection Report
Census: 55
Capacity: 60
Deficiencies: 1
Date: Aug 27, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing service requirements, specifically regarding the designation of a Registered Nurse as Director of Nurses (DON) following the resignation of the previous DON.
Findings
The facility failed to ensure a Registered Nurse was designated as the Director of Nurses from 3/8/19 through 8/12/19. Interviews revealed confusion and lack of official notification regarding the DON position, with the Assistant Director of Nurses not officially appointed as DON and the Administrator temporarily assuming the role without proper designation.
Deficiencies (1)
Failure to ensure a Registered Nurse was designated as Director of Nurses from 3/8/19 through 8/12/19.
Report Facts
Residents affected: 55
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN EE | Registered Nurse | Interviewed regarding the Administrator acting as DON. |
| LPN AA | Licensed Practical Nurse | Interviewed about notification of DON resignation. |
| CNA BB | Certified Nursing Assistant | Interviewed about notification of DON resignation. |
| CNA CC | Certified Nursing Assistant | Interviewed about notification of DON resignation. |
| LPN DD | Licensed Practical Nurse | Interviewed about notification of DON resignation. |
| ADON | Assistant Director of Nurses / Vice President of Healthcare Services | Interviewed regarding designation as DON and duties performed. |
| HR Director | Human Resources Director | Interviewed regarding notification process for DON changes. |
| Medical Director | Medical Director | Interviewed about knowledge of DON designation after resignation. |
| Administrator | Facility Administrator | Interviewed regarding acting as DON and designation letters. |
| Compliance Officer | Compliance Officer | Interviewed about awareness of DON appointment. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 29, 2019
Visit Reason
A complaint survey was conducted to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 12, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited deficiencies had been corrected.
Findings
The surveyor noted that all previously cited tags have been corrected.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
A standard survey was conducted at LenBrook from November 5, 2018 through November 8, 2018 to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Inspection Report
Life Safety
Census: 57
Capacity: 60
Deficiencies: 5
Date: Nov 5, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper installation of smoke detectors, lack of documentation for smoke detector sensitivity testing, missing sprinkler head in a hallway alcove, absence of a remote annunciator for the emergency generator, and failure to conduct an annual load bank test on the generator.
Deficiencies (5)
Failed to install approximately 4 smoke detectors more than 36 inches from the air flow stream in prep and clean linen rooms on multiple floors.
Failed to provide documentation on the sensitivity report for all smoke detectors on the 2nd, 3rd, and 4th floors.
Failed to install a sprinkler head within the 6ft alcove off the hallway on the 2nd floor.
Failed to provide a remote annunciator for the generator for the LTC on floors 2, 3, and 4.
Failed to conduct an annual load bank test for the generator.
Report Facts
Census: 57
Total Capacity: 60
Number of smoke detectors improperly installed: 4
Number of residents at risk due to sprinkler deficiency: 2
Number of staff at risk due to sprinkler deficiency: 2
Number of residents at risk due to smoke detector deficiency: 6
Number of staff at risk due to smoke detector deficiency: 4
Number of residents at risk due to generator deficiencies: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour |
Inspection Report
Routine
Census: 52
Deficiencies: 0
Date: Nov 22, 2017
Visit Reason
A standard survey was conducted at Lenbrook from November 20, 2017 through November 22, 2017 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.
Report Facts
Resident Census: 52
Inspection Report
Life Safety
Census: 51
Capacity: 60
Deficiencies: 0
Date: Nov 21, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
Lenbrook was found in substantial compliance with the Life Safety Code requirements at 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 Edition.
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