Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Lenbrook during CMS and state inspections, most recent first.
A facility failed to follow infection prevention and control practices for two residents and did not maintain required surveillance documentation. During wound care for one resident, an LPN used a reusable marker and placed it in her pocket without disinfecting it. During medication administration for another resident, a pill dropped on an uncleaned med cart was picked up, crushed, and given, and hand hygiene was not performed between glove changes. The facility’s documented audits were limited to hand hygiene and did not include other key infection control areas.
A resident with contracture, L hemiplegia, and a CVA history had a restorative nursing plan for a rolled washcloth splint to the L hand and a pillow between the knees to maintain ROM and prevent further contractures. Survey observations found the resident several times in a Geri chair or in bed with the L hand contracted and no washcloth or splint in place, although one later observation did show a rolled washcloth in the hand. Staff said the task shifted from restorative nursing to floor staff after restorative services were discontinued, and the DON stated the charge nurse was responsible for checking completion.
A resident with dementia and mobility issues was unable to reach the call light, which was placed on a nightstand far from her recliner. The resident struggled to summon assistance, expressing frustration and a need to use the restroom. CNAs adjusted the recliner's position, and the DON emphasized the importance of accessible call lights for resident safety.
A resident's nasal cannula, used for oxygen therapy, was found on the floor and improperly reused without cleaning or replacement, violating the facility's infection control policy. The CNA involved acknowledged the error, and the LPN replaced the equipment after being informed. The incident highlighted a failure to adhere to established protocols for preventing infections.
The facility failed to apply a 14-day stop date for PRN orders of psychotropic medications for two residents, as required by their policy. An LPN and the DON confirmed the oversight, acknowledging that the orders for lorazepam lacked the necessary stop date, leading to multiple administrations over several weeks.
Infection Control Lapses During Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain infection prevention and control practices for two residents, including R8 and R28, and also failed to keep its infection prevention and control program and surveillance activities current. The facility policy required annual review of infection control policies and surveillance tools to monitor adherence to infection prevention and control practices, but the infection surveillance audits on file were limited to hand hygiene and did not include dates or frequency. No documented audits were completed for wound care practices, isolation precautions, medication administration, environmental cleaning, or reusable equipment disinfection. The Infection Preventionist stated that auditing and surveillance processes had been under development since January 2026 and that weekly visual audits were being done, but documentation was only available for hand hygiene. The DON confirmed that the reusable black marker used during wound care should have been sanitized before being placed back into the nurse's pocket. During wound care for R8, who had diagnoses including hip fracture, paraplegia, malnutrition, and depression and was cognitively intact with a BIMS score of 14, the LPN used a reusable black marker to date the bandage and then placed the marker directly into her uniform pocket without disinfecting it after leaving the room. During medication administration for R28, who had diagnoses including heart failure, hypertension, seizure disorder or epilepsy, and asthma and had a BIMS score of 11, a pill dropped onto the uncleaned medication cart was picked up, crushed, and given to the resident. The resident was also given an inhaler, gloves were removed and replaced with clean gloves to perform an eye scrub, and hands were not washed between glove changes. The LPN stated she knew the handwashing policy when gloves were changed and thought she had cleaned the top of her cart, but she did not usually place a barrier on it.
Restorative splinting and ROM not consistently provided
Penalty
Summary
The facility failed to provide evidence that restorative nursing services for splinting and range of motion (ROM) were consistently provided for one sampled resident with contracture, left hand flaccid hemiplegia, and a history of cerebral infarction due to embolism of the right middle cerebral artery. The facility policy for Restorative Nursing Services stated that restorative nursing consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services. R61’s care plan included a restorative nursing program for contracture management with a rolled washcloth splint to the left hand and a pillow between the knees to maintain ROM and prevent further contractures. Record review showed the splint/brace assistance program had been initiated, and restorative notes later stated the resident had been discontinued from restorative and turned over to floor staff to continue the washcloth in hand and pillows between the knees. However, observations on multiple occasions found the resident in a Geri chair or in bed with the left hand contracted and no washcloth or splint observed. On one later observation, a rolled washcloth was present in the resident’s left hand. Staff interviews indicated that after restorative nursing was discontinued, floor staff were responsible for the hand roll or splint, and the DON stated restorative aides applied splints or hand rolls in the morning before the task was turned over to floor staff, with the charge nurse responsible for checking completion.
Inaccessible Call Light Poses Risk to Resident Safety
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is crucial for meeting care needs, safety, and fall prevention. The resident, who has diagnoses including dementia, impaired physical mobility, and cognitive deficits, was observed seated in a recliner with the call light placed on a nightstand by the bed, far from her reach. The resident demonstrated difficulty in summoning assistance, as she struggled with the remote for her recliner and was unable to reach the call light, expressing frustration and a need to use the restroom. During an interview, a CNA acknowledged the inaccessibility of the call light and sought assistance from another CNA. Together, they moved the resident's recliner closer to the nightstand. The Director of Nursing confirmed that all call lights must be within easy reach of residents to ensure timely assistance, noting that inaccessible call lights increase the risk of harm to residents who cannot summon help.
Failure to Replace Contaminated Respiratory Equipment
Penalty
Summary
The facility failed to adhere to its infection control protocols regarding respiratory care equipment, specifically for a resident requiring oxygen therapy. The deficiency was observed when a nasal cannula, used by a resident with diagnoses including dementia, chronic rhinitis, COPD, and hypoxemia, was found unbagged and lying on the floor. A Certified Nursing Assistant (CNA) retrieved the nasal cannula from the floor and placed it back in the resident's nose without cleaning or replacing it, contrary to the facility's policy that mandates discarding and replacing equipment that comes into contact with non-sterile surfaces. The incident was further compounded when another CNA entered the room, observed the situation, and reminded the first CNA of the correct protocol. The first CNA acknowledged the mistake but had not replaced the equipment immediately. The Licensed Practical Nurse (LPN) was informed and subsequently replaced the nasal cannula. Interviews with the involved staff and the Director of Nursing confirmed the expectation that all respiratory equipment must be discarded if contaminated to prevent infections, highlighting a lapse in following established infection control procedures.
Failure to Implement 14-Day Stop Date for Psychotropic Medications
Penalty
Summary
The facility failed to implement a 14-day stop date for PRN orders of psychotropic medications for two residents, leading to a deficiency in medication management. The facility's policy on psychotropic medication use, dated July 2022, mandates that PRN orders for such medications should not exceed 14 days. However, a review of clinical records revealed that Resident 7 had an ongoing PRN order for lorazepam without a stop date, which was administered multiple times over several weeks. Similarly, Resident 21 had a PRN order for lorazepam without a stop date, and the medication was administered on several occasions. Interviews with facility staff, including an LPN and the DON, confirmed the oversight in applying the 14-day stop date to these psychotropic medications. The LPN, responsible for auditing charts, acknowledged the absence of a stop date for Resident 21's lorazepam as an oversight. The DON also confirmed the expectation for all psychotropic medications to have a 14-day stop date unless otherwise indicated by a physician, acknowledging the oversight in the cases of Residents 7 and 21.
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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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How nearby facilities compare on the same public inspection record.
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| Perimeter Rehabilitation Suites By Harborview | 1.9 mi | — | 25 | 1 |
| Nurse Care Of Buckhead | 2.7 mi | ★★★★★ | 6 | 0 |
| A.g. Rhodes Home Wesley Woods | 2.8 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Brookhaven | 3 mi | ★★★★★ | 19 | 0 |
| Sandy Springs Center For Nursing And Healing Llc | 3.1 mi | ★★★★★ | 11 | 0 |
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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.