Cycle 1
Health 2025-06-15 · Fire 2025-06-15
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Waynesboro, GA
Brentwood Health Center by Harborview
2-star overall rating with 2-star inspections with $3,145 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
115 Brentwood Drive, Waynesboro, GA
(706) 554-4425
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1989-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.25
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.49
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,641
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.92
Baseline 28.12% · Performance 51.72% · Measure score 2.92 · Achievement 2.92 · Improvement 0
Adjusted total nurse staffing
3.51
Baseline 3.56 hours · Performance 4.08 hours · Measure score 3.51 · Achievement 3.51 · Improvement 1.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.57% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 19.23% · Lower 95% interval 7.88% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 48.28% |
53.69%
5.4 pts worse
|
Numerator 14 · Denominator 29 |
| Discharge mobility score | 34.48% |
50.94%
16.5 pts worse
|
Numerator 10 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 7.89% |
2.29%
5.6 pts worse
|
Numerator 3 · Denominator 38 · Adjusted rate 5.75% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 127 |
| Staff flu vaccination coverage | 24.74% |
42%
17.3 pts worse
|
Numerator 24 · Denominator 97 |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 16 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
91.2%
8 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
95.0%
3.6 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.2%
2.2 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.8% · Q3 4.5% · Q4 4.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 12.4% |
5.9%
6.5 pts worse
|
5.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.1% · Q3 15.6% · Q4 11.4% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.2% |
20.7%
5.5 pts worse
|
19.6%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 24.4% · Q3 31.2% · Q4 27.7% · 4Q avg 26.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.1% |
21.4%
10.7 pts worse
|
16.7%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 25.8% · Q3 29.7% · Q4 34.3% · 4Q avg 32.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.2% |
17.9%
12.3 pts worse
|
16.3%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
16.2%
8.6 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 35.1% · Q3 16.7% · Q4 20.9% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 0.8% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.5%
1.3 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 9.1% · Q3 1.6% · Q4 1.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
16.1%
3.1 pts worse
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 29.0% · Q3 14.9% · Q4 14.4% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
6.2%
4 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 14.4% · Q3 11.9% · Q4 3.8% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
80.4%
14.9 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 96.5% · Q3 93.9% · Q4 93.2% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
12.2%
1.6 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 14.8% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
78.2%
12.4 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.9% |
24.2%
16.3 pts better
|
23.9%
16 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.4% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-15
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-07-21
F · Potential for more than minimal harm
2023-08-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-08-24
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-15
C · Minimal harm
2025-06-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-15
D · Potential for more than minimal harm
2023-08-24
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-06
Penalties and ownership
What sits behind the stars
$3,145
2023-05-15
Fine
Fine · fine $3,145
Fine
Ownership
Westbury, James R
5% Or Greater Indirect Ownership Interest · Individual
Davis Iii, William C
5% Or Greater Indirect Ownership Interest · Individual
Davis, William
5% Or Greater Indirect Ownership Interest · Individual
Orne, David
5% Or Greater Indirect Ownership Interest · Individual
Windham, Ashton
5% Or Greater Indirect Ownership Interest · Individual
Windham, Spencer
5% Or Greater Indirect Ownership Interest · Individual
Davis Iii, William C
Operational/Managerial Control · Individual
Davis, William
Operational/Managerial Control · Individual
Orne, David
Operational/Managerial Control · Individual
Parker, David
5% Or Greater Indirect Ownership Interest · Individual
Parker, David
Operational/Managerial Control · Individual
Westbury, James R
Operational/Managerial Control · Individual
Windham, Ashton
Operational/Managerial Control · Individual
Windham, Spencer
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Keysville Nursing Home & Rehab
Blythe, GA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Gracewood Nsg Facility(Unit 9)
Gracewood, GA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Bethany
Millen, GA
2-star overall rating with 2-star inspections with $91,062 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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