Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Brightmoor Nursing Center, Llc during CMS and state inspections, most recent first.
Two residents with severe cognitive deficits were involved in an incident in which one resident, diagnosed with non-traumatic brain dysfunction and dementia, placed a pillow over the face of another resident with CAD, HTN, BPH, hyponatremia, and hyperlipidemia. The facility’s investigation and interviews with the DON and Administrator/Abuse Coordinator confirmed this as substantiated resident-to-resident abuse, in violation of the facility’s abuse, neglect, and exploitation policy that is intended to preserve each individual’s right to be free from mistreatment and abuse.
Food Items Left Unlabeled, Undated, and Past Expiration: Surveyors observed multiple food items in dry storage, the refrigerator, and the freezer that were unlabeled, undated, or missing open/use-by dates, including cake mix, dry goods, sliced oranges, pudding, dressing, and turkey. Staff confirmed some items had been prepared but not yet labeled, and the RD/DM verified that food items should be labeled and dated with the received date, open date, and expiration or use-by date.
A resident with a history of behavioral issues and moderate cognitive impairment repeatedly used foul and threatening language, including a death threat, toward his cognitively intact roommate. Despite attempts by a CNA and an LPN to redirect the abusive resident, the interventions were unsuccessful, resulting in the roommate feeling uncomfortable and requesting a room change. The incident was reported to social services, and an involuntary mental health evaluation was initiated for the abusive resident.
Two residents were involved in a verbal abuse incident where one resident, with moderate cognitive impairment, threatened and used foul language toward his roommate. Staff attempted to intervene and separate the residents, and a mental health evaluation was initiated for the aggressive resident. However, the Social Service Director did not follow the facility's abuse investigation policy, failed to notify authorities, and did not document or conduct a thorough investigation, resulting in a deficiency.
Failure to obtain consent for psychotropic medications: The facility had no signed consent in the EMR for two residents receiving psychotropic meds. One resident had severe cognitive impairment with diagnoses including Alzheimer’s disease, schizophrenia, psychosis, depression, and anxiety, and active orders for clonazepam, quetiapine, and escitalopram. The other resident had moderate cognitive impairment with dementia, psychotic disturbance, mood disturbance, and anxiety, and active orders for lorazepam, quetiapine, and escitalopram. The RP for one resident did not recall signing consent, and the DON acknowledged the missing consents.
Failure to assess a resident’s ability to self-administer medication before leaving cyclosporine eye drops at the bedside. The resident had intact cognition on MDS, but the chart had no self-administration assessment, no care plan, and no order for self-administration. During observation, RN found eight vials of the eye drops at the bedside, and the resident stated she had been taking them on her own for a long time. The LPN/UM and DON confirmed the resident should not have been self-administering the drops without an order.
The facility failed to develop comprehensive care plans for two residents. One resident had an indwelling urinary catheter with active orders for catheter care, but no care plan addressed that need. Another resident had an active order for an electronic alert system device related to exit-seeking behavior, but no care plan was developed for that device. MDS staff acknowledged the omissions, and the Administrator stated these needs should have been addressed in the residents’ care plans.
A resident’s room contained rubbing alcohol, hydrogen peroxide, and liquid Benadryl stored on the back of the door, even though there were no physician orders for those items. The resident was cognitively intact and used a walker or wheelchair with partial to moderate assistance. A CNA and an LPN both confirmed the items were present and said they should not have been in the room, and the DON later confirmed the items did not belong there.
An unlocked medication cart was left unattended on the hall, expired Heparin Lock Flush syringes were found in a medication room, and a bottle of blood glucose strips on a medication cart had no open date. RN BB confirmed the cart was unsecured, LPN AA confirmed the expired syringes and missing strip date, and the DON stated expired meds should not be in medication rooms and glucose strips should have open and discard dates.
Hand Hygiene Not Performed Between Glove Changes: An LPN was observed removing gloves, putting on a new pair without sanitizing her hands, and cleaning a blood pressure cuff beside the med cart. She then removed the second pair of gloves and went to the med room for medications without hand hygiene after glove removal. The LPN confirmed the lapse, and the DON and IP stated hand hygiene was expected between glove changes and after glove removal.
Resident-to-Resident Abuse Involving Pillow Over Face
Penalty
Summary
The facility failed to protect a resident from abuse when one cognitively impaired resident placed a pillow over the face of another cognitively impaired resident. The resident identified as the victim, R6, had been admitted with diagnoses including coronary artery disease, hypertension, benign prostatic hyperplasia, hyponatremia, and hyperlipidemia, and had a Brief Interview for Mental Status (BIMS) score of three, indicating a severe cognitive deficit. The resident identified as the aggressor, R5, had been admitted with non-traumatic brain dysfunction and dementia and also had a BIMS score of three, indicating a severe cognitive deficit. During the incident on 1/6/2026, R5 placed a pillow over R6’s face. The facility’s own investigation documented that the act of placing the pillow over R6’s face occurred and was substantiated as resident-to-resident abuse. The facility’s policy titled “Abuse, Neglect, and Exploitation” states that its intent is to actively preserve each individual’s right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Interviews with the DON and the Administrator/Abuse Coordinator confirmed that the incident between R5 and R6 met the definition of abuse under facility policy and that resident-to-resident abuse was confirmed. This sequence of events demonstrates that the facility did not ensure that R6 was free from abuse as required by its policy and regulatory standards.
Food Items Left Unlabeled, Undated, and Past Expiration
Penalty
Summary
The facility failed to ensure proper food labeling, dating, and storage, and failed to ensure food items were not available for resident consumption past their expiration date. During a kitchen tour with the Assistant Dietary Director, the surveyor observed an unlabeled and undated wrapped powder identified as cake mix in dry storage, along with multiple other dry goods that had no open or discard dates, including cornmeal, Worcestershire sauce, liquid smoke, gelatin, baking soda, pomace oil, and vegetable oil. A container of confectioners' powdered sugar was also observed with an expiration date of 11/19/2025 and no open date. In the reach-in refrigerator, surveyors observed nine unlabeled and undated containers of sliced oranges and 15 containers of yellow pudding. In the walk-in freezer, two half-sheet pans of dressing were observed with an expiration date of 12/17/2025, and one-half turkey had no use-by date on the label. A rack in the kitchen contained 91 assorted puddings intended for lunch that were neither labeled nor dated. Staff interviews confirmed the pudding-like items had been prepared that morning and were planned to be labeled later, and the RD/DM confirmed that all items should be labeled and dated with the received date, open date, and expiration or use-by date.
Failure to Protect Resident from Verbal Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with a history of behavioral issues, including yelling and making inappropriate comments, verbally abused his roommate. The abusive resident, who had moderate cognitive impairment and a documented risk for behaviors, repeatedly used foul and threatening language toward his roommate, including a threat to kill him. Staff members, including a CNA and an LPN, attempted to redirect the abusive resident without success. The roommate, who was cognitively intact and had diagnoses including anxiety disorder and major depressive disorder, reported feeling very uncomfortable and requested a room change due to the repeated verbal abuse. The facility's policy prohibits all forms of abuse, including verbal abuse, and requires interventions to protect residents' rights and safety. Despite these policies and the known behavioral risks of the abusive resident, staff were unable to prevent the verbal abuse or effectively intervene to stop the threatening behavior. The situation escalated to the point where the abusive resident admitted to making threats, and staff initiated an involuntary mental health evaluation. The incident was reported to social services, but the initial staff interventions were unsuccessful in protecting the resident from verbal abuse.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough and timely investigation following an allegation of resident-to-resident verbal abuse involving two residents. One resident, with little to no cognitive impairment, reported feeling uncomfortable and requested a room change after his roommate repeatedly used foul language towards him. Progress notes indicated that the other resident, who had moderate cognitive impairment and a history of restlessness and agitation, was observed rummaging through his roommate's belongings and made threatening statements, including a threat to kill his roommate. Staff attempted to redirect the aggressive resident without success, and the residents were separated. A mental health evaluation was initiated for the aggressive resident. Despite the seriousness of the incident, the Social Service Director (SSD) did not follow the facility's abuse investigation policy. The SSD acknowledged being informed of the threat and attempted to de-escalate the situation but did not contact law enforcement or the Ombudsman, and failed to document interviews or conduct further investigative tasks. Other staff, including an LPN, witnessed the incident but did not provide additional documentation. The Director of Nursing and Administrator confirmed that proper reporting and investigative procedures were not followed, and no investigation file could be located for the incident.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent from the resident or responsible party for the use of psychotropic medications for two residents, R16 and R21, who were sampled for unnecessary medications. The facility policy titled Resident Rights stated that residents have the right to be informed of, and participate in, their care planning and treatment. Review of R16’s record showed diagnoses including Alzheimer’s disease, unspecified schizophrenia, unspecified psychosis, delusional disorders, major depressive disorder, and generalized anxiety disorder. R16’s quarterly MDS documented a BIMS score of 5 out of 15, indicating severe cognitive impairment. Active orders included clonazepam as needed for anxiety, quetiapine at bedtime for unspecified psychosis, and escitalopram for depression, but the EMR contained no signed consent for these psychotropic medications. R16’s RP, identified as a daughter, stated she was not familiar with a consent and did not remember signing one. Review of R21’s record showed diagnoses including unspecified dementia with psychotic disturbance, mood disturbance, and anxiety. R21’s quarterly MDS documented a BIMS score of 8 out of 15, indicating moderate cognitive impairment. Active orders included lorazepam as needed for anxiety, quetiapine at bedtime for sleep, and escitalopram for depression, and the EMR also contained no signed consent for psychotropic medication use. During interview, the DON acknowledged that there were no consents for the use of psychotropic medications for R16 and R21 and stated that residents on psychotropic medications should have a signed consent from the resident and/or RP.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess one of 48 sampled residents, R8, for the ability to safely self-administer medications before leaving medications at the bedside. The facility policy titled Self-Administration of Medications stated that residents may self-administer medications if they are determined to be capable, and that staff and the practitioner should assess the resident’s mental and physical abilities, including the ability to read labels, understand purpose and dosage, remove medications from containers, and recognize risks and adverse consequences. However, the clinical record contained no assessment for self-administration and no care plan for it, and there was no order for self-administration of medication. R8 was admitted with diagnoses including Sjogren syndrome, muscle weakness, and symptoms and signs involving cognitive functions following cerebral infarction. The MDS assessment documented a BIMS score of 15, indicating intact cognition. During observation, a cup containing eight vials of cyclosporine ophthalmic solution was found at R8’s bedside, and RN GG stated that R8 used the medication herself. R8 stated that she had been taking the eye drops by herself when needed and usually around lunchtime for dry eyes, and that she had been self-administering them at the facility for a long time. LPN/UM DD confirmed the eyedrops were at the bedside and stated she was not aware R8 was using them unattended, while also confirming there was no order for self-administration. The DON stated that R8 should not have medications at the bedside nor self-administer the eye drops and was not aware that R8 was taking them on her own.
Incomplete Care Plans for Catheter and Alert Device Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, R109 and R14. Review of R109’s admission MDS dated 10/11/2025 showed that Section H documented an indwelling urinary catheter, and the Order Summary Report listed active orders for an indwelling urinary catheter and catheter care. However, the care plan for R109 did not include a care plan for the indwelling urinary catheter. Observations on 12/19/2025 at 8:50 am, 12/20/2025 at 12:35 am, and 12/21/2025 at 8:30 am showed R109 with an indwelling urinary catheter. Review of R14’s physician orders showed an active order for an electronic alert system device related to exit-seeking behavior, but the care plan did not include a care plan for the device. During interviews, the MDS Coordinator stated that admission assessments and physician orders are used to identify care areas and acknowledged that R109 did not have a care plan for the indwelling urinary catheter due to an oversight. Another MDS Coordinator stated that R14 should have been care planned for the electronic alert system device. The Administrator stated that all residents with an indwelling urinary catheter or electronic alert system device should have those needs addressed in their care plans.
Hazardous Items Stored in Resident Room
Penalty
Summary
The facility failed to ensure that one sampled resident’s room was free from accident hazards when rubbing alcohol, hydrogen peroxide, and liquid Benadryl were found stored on the back of the resident’s room door. The resident, who was admitted with diagnoses including unspecified anxiety disorder and unspecified rheumatoid arthritis, had a BIMS score of 15 on the quarterly MDS, indicating cognitive intactness, and required partial to moderate assistance with mobility using a walker or wheelchair. The physician’s orders did not include rubbing alcohol, hydrogen peroxide, or Benadryl. Observations on multiple occasions showed the same three items present in the room. A CNA confirmed the items were in the room and stated they should not have been there. An LPN also confirmed the items were present, stated she had not previously seen them, and acknowledged they should not have been in the room. The resident gave the LPN permission to remove the items. The DON later confirmed that the items identified should not be in the resident’s room and stated the facility provides education to families regarding these expectations.
Unlocked Medication Cart, Expired Heparin Syringes, and Missing Open Date on Blood Glucose Strips
Penalty
Summary
One medication cart on the 500 Hall was observed unlocked and unattended on two separate occasions. During the first observation, RN BB was seen walking from the end of the hallway and came to lock the cart, and she confirmed it had been left unlocked and unattended. She stated that residents may open the cart and take medications from it, and that the medications may not be the ones they should take and residents could get hurt. During the second observation, RN BB stated she had left the cart unlocked and unattended while she was at the nurses' station. In the 500 Hall medication room, a bag containing 30 Heparin Lock Flush solution 50 units/5 ml single-use sterile syringes was found in the bottom cupboard beside the refrigerator with an expiration date of 9/30/2025. LPN AA confirmed all of the syringes were expired and stated the heparin solution was used to keep IV ports free of blood clots. In addition, a bottle of blood glucose strips on the 600 Hall medication cart had no open date. LPN AA stated the strips should have an open date because they could lose effectiveness after 30 days, and the bottle instructions stated to indicate the first opening date on the bottle. The DON stated expired medications should not be in the medication rooms and that blood glucose strips should have open and discard dates.
Hand Hygiene Not Performed Between Glove Changes
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when an LPN did not perform hand hygiene between glove changes and after removing gloves. During observation on 12/20/2025 at 9:20 am, the LPN removed and disposed of gloves after exiting a resident room, then put on a new pair of gloves without sanitizing her hands and cleaned the blood pressure cuff attached to the blood pressure machine beside the medication cart. She then removed the second pair of gloves, disposed of them, and went to the medication storage room to obtain medications for the medication cart without sanitizing her hands after glove removal. During interview, the LPN confirmed she did not sanitize her hands between glove changes and stated she should have done so to prevent the spread of infection and cross-contamination. The DON stated staff were expected to wash their hands or use hand sanitizer between glove changes and after removing gloves, and the IP stated hand hygiene should be performed between glove changes and after removing gloves to prevent cross-contamination and the spread of infection to residents.
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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.
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Nursing homes near Griffin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spalding Post Acute Llc | 4.8 mi | ★★★★★ | 11 | 0 |
| Pruitthealth - Griffin | 5.3 mi | ★★★★★ | 0 | 0 |
| Fayetteville Center For Nursing & Healing Llc | 16.5 mi | ★★★★★ | 7 | 0 |
| Heritage Inn Of Barnesville Health And Rehab | 17.8 mi | ★★★★★ | 0 | 0 |
| Westbury Center Of Mcdonough For Nursing & Healing | 17.9 mi | ★★★★★ | 3 | 2 |
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