Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The William Breman Jewish Home during CMS and state inspections, most recent first.
CPAP care was not properly managed for a resident with sleep apnea. The resident’s CPAP unit had no physician order, the CPAP supplies were left unbagged and unlabeled, the opened distilled water was undated, and nightly CPAP use was not documented. An LPN confirmed the equipment and water were not properly labeled, and the DON confirmed the lack of order, documentation, and labeling.
The facility was found deficient in food storage and sanitation practices, with unlabeled and expired food items in the cooler and dry storage, and an unclean ice machine. Staff interviews revealed lapses in responsibility and adherence to food safety protocols.
A resident's advanced directive records were not properly updated in the facility's EHR, leading to a discrepancy between the documented CPR order and the resident's DNR wishes. RN AA admitted to the oversight, and both the DON and Administrator confirmed the importance of accurately entering orders to honor the resident's preferences.
The facility failed to maintain a medication error rate below five percent, resulting in a ten percent error rate. An LPN attempted to administer incorrect medications to a resident, leading to two errors. Another LPN was observed giving an extra dose of vitamin C to a different resident, resulting in another error. Interviews confirmed the errors, and the administration emphasized adherence to physician's orders and the five rights of medication administration.
CPAP Care Not Properly Ordered, Labeled, or Documented
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for R29, who was admitted with unspecified sleep apnea and had a BIMS score of 15 with no cognitive impairment. The care plan included a focus on altered respiratory status/difficulty breathing related to sleep apnea and listed interventions for CPAP use at bedtime, cleaning the CPAP mask, cleaning the CPAP weekly, and filling the machine with distilled water. However, the facility did not produce a policy related to PAP devices, and there were no physician orders related to CPAP even though the resident’s family supplied the unit. Observations of R29’s room showed a CPAP unit and supplies left unbagged and undated, along with a half-full jug of distilled water that was also undated. The same condition was observed on multiple occasions, and an LPN confirmed the equipment was unbagged and unlabeled and that the opened distilled water was undated. He also stated there was no documentation of CPAP supply changes because there was no physician order for the unit, and that staff sometimes assisted the resident with applying the CPAP mask while at other times she applied it herself. The DON confirmed the CPAP unit should have had a physician order, use should have been documented, the mask should have been bagged and labeled with the date of setup or change out, and the distilled water should have been dated when opened.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, labeling, and sanitation, leading to several deficiencies. During an inspection, it was observed that the ice machine was not properly cleaned, as evidenced by a brown/red substance inside. Additionally, various food items in the reach-in cooler, including fruit cups, pitchers of liquid, condiment cups, and a plate of assorted fruits, were found unlabeled and undated. In the dry storage area, three packages of flour tortillas were discovered to be expired. These observations indicate a lack of compliance with the facility's policies on food safety and sanitation. Interviews with facility staff revealed gaps in the execution of responsibilities related to food safety and equipment maintenance. The Dietary Supervisor acknowledged that labeling and dating were collective responsibilities, but errors were still present despite regular checks. The Facility Tech II, responsible for cleaning the ice machine, admitted to possibly rushing the cleaning process, which might have led to inadequate cleaning of the seals. The Dietary Manager confirmed the deficiencies in labeling, dating, and expiration of food items, attributing the responsibility for the reach-in refrigerator items to one of the servers. These interviews highlight a breakdown in communication and accountability among staff members regarding food safety protocols.
Failure to Update Advanced Directive Records
Penalty
Summary
The facility failed to properly maintain and update the advanced directive records for a resident, identified as R12, which could potentially lead to the resident's wishes not being honored in a medical emergency. R12, who was admitted with diagnoses including dementia and chronic lymphocytic leukemia, had a documented advanced directive for CPR in the electronic health record (EHR). However, there were conflicting documents indicating a Do Not Resuscitate (DNR) order, which was not updated in the EHR. This discrepancy was confirmed by RN AA, who admitted to forgetting to update the code status from CPR to DNR, acknowledging the oversight and the potential for the resident's wishes to be disregarded. The Director of Nursing (DON) and the Administrator both confirmed the protocol for handling POLST forms and advanced directives, emphasizing the importance of accurately entering the orders into the EHR. The DON reviewed the incorrect orders and confirmed that the information should be entered accurately according to the resident's wishes. The Administrator reiterated the protocol to ensure the patient's wishes were honored, highlighting the potential negative outcome of not following the orders accurately. The failure to update the advanced directive in the EHR was identified as a deficiency in the facility's process, with the potential to result in actions that did not align with the resident's preferences.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a ten percent error rate. During a medication administration observation, an LPN attempted to administer incorrect medications to a resident. The resident was supposed to receive acetaminophen 650 mg and aspirin 81 mg daily, as per the physician's orders. However, the LPN took two 325 mg acetaminophen tablets and one aspirin 81 mg from the floor stock, which was incorrect. This action resulted in two medication errors, as the LPN was about to administer the wrong dosage before being stopped by the surveyor. In another instance, a different LPN was observed administering morning medications to another resident. The resident's physician orders included vitamin C 500 mg daily. The LPN, however, attempted to give an additional vitamin C tablet from the floor stock, despite it already being included in the prefilled medication pouch. This resulted in another medication error, as the LPN was about to administer an extra dose before the surveyor intervened. Interviews with the LPNs confirmed the errors, and the facility's administration expressed their expectation for medications to be administered according to physician's orders and the five rights of medication administration.
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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 Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nurse Care Of Buckhead | 3.1 mi | ★★★★★ | 6 | 0 |
| Perimeter Rehabilitation Suites By Harborview | 3.2 mi | — | 25 | 1 |
| Buckhead Center For Nursing & Healing | 4.2 mi | ★★★★★ | 2 | 0 |
| Terraces At Peachtree Hills Place, The | 4.2 mi | ★★★★★ | 5 | 0 |
| Lenbrook | 4.5 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.