Cycle 1
Health 2025-12-21 · Fire 2025-12-21
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Griffin, GA
Brightmoor Nursing Center, LLC
2-star overall rating with 3-star inspections with 9 recent health deficiencies
3235 Newnan Road, Griffin, GA
(770) 228-8599
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
133
Certified beds
Average residents
128
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.27
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,923
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.29% · Performance 25.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.61
Baseline 8.55% · Performance 8.16% · Measure score 0.61 · Achievement 0 · Improvement 0.61
Total nurse turnover
3.24
Baseline 50.00% · Performance 50.43% · Measure score 3.24 · Achievement 3.24 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.18 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.86% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 374 · Observed rate 13.1% · Lower 95% interval 9.68% |
| Discharge to community | 59.57% |
50.57%
9 pts better
|
Better than the National Rate · Eligible stays 355 · Observed rate 55.49% · Lower 95% interval 53.69% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.4% |
95.27%
2.1 pts better
|
Numerator 225 · Denominator 231 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 231 |
| Discharge self-care score | 43.87% |
53.69%
9.8 pts worse
|
Numerator 68 · Denominator 155 |
| Discharge mobility score | 36.77% |
50.94%
14.2 pts worse
|
Numerator 57 · Denominator 155 |
| Pressure ulcers or injuries, new or worsened | 2.6% |
2.29%
0.3 pts worse
|
Numerator 6 · Denominator 231 · Adjusted rate 2.21% |
| Healthcare-associated infections requiring hospitalization | 8.16% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 240 · Observed rate 8.33% · Lower 95% interval 5.85% |
| Staff COVID-19 vaccination coverage | 0.49% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 203 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 49.68% |
56.45%
6.8 pts worse
|
Numerator 77 · Denominator 155 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 159 · Denominator 159 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 14 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
91.2%
2.8 pts worse
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.5% · Q2 90.7% · Q3 100.0% · Q4 100.0% · 4Q avg 88.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
95.0%
2.1 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.2%
1.9 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
9.6%
9.3 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.9%
1.3 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.6% · Q3 10.7% · Q4 1.4% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.2% |
20.7%
11.5 pts worse
|
19.6%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 28.2% · Q3 31.6% · Q4 33.8% · 4Q avg 32.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
21.4%
3 pts better
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 18.5% · Q3 22.7% · Q4 18.6% · 4Q avg 18.4% · 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 | 64.5% |
17.9%
46.6 pts worse
|
16.3%
48.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 64.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.7% |
16.2%
20.5 pts worse
|
14.9%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 37.3% · Q3 34.3% · Q4 40.6% · 4Q avg 36.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.1%
0.3 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 2.6% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 1.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
16.1%
6.9 pts worse
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 25.4% · Q3 22.3% · Q4 22.7% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.2%
0.7 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.2% · Q3 7.6% · Q4 7.4% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
80.4%
9.1 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 88.8% · Q3 94.4% · Q4 88.6% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
12.2%
4.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.2%
0.5 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.9% · Q3 3.0% · Q4 2.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
78.2%
2.2 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
24.2%
1.3 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 25.9% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-07 · Fire 2024-11-07
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2023-05-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-21
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 2026-02-13
D · Potential for more than minimal harm
2025-12-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-21
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 2026-02-13
D · Potential for more than minimal harm
2025-12-21
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 2026-02-13
D · Potential for more than minimal harm
2025-12-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-13
D · Potential for more than minimal harm
2023-05-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-18
D · Potential for more than minimal harm
2023-05-04
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 2023-06-18
D · Potential for more than minimal harm
2023-05-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-18
Penalties and ownership
What sits behind the stars
Ownership
Brightmoor Griffin Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Brightmoor Griffin Holdings LLC
Operational/Managerial Control · Organization
Brightmoor Management Services LLC
Operational/Managerial Control · Organization
Brown, William
Operational/Managerial Control · Individual
Brown, William
Corporate Officer · Individual
Doherty, Brian
5% Or Greater Indirect Ownership Interest · Individual
Hoplite Brightmoor Seniors LLC
5% Or Greater Indirect Ownership Interest · Organization
Hoplite Capital Strategies LLC - Brightmoor Series
5% Or Greater Indirect Ownership Interest · Organization
Lykouretzos, John
5% Or Greater Indirect Ownership Interest · Individual
Reese, Howard
Operational/Managerial Control · Individual
Reese, Howard
Corporate Officer · Individual
West, Randall
Operational/Managerial Control · Individual
West, Randall
W-2 Managing Employee · Individual
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#3
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