10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Decatur, GA
1-star overall rating with 1-star inspections with abuse icon flag with $13,043 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4115 Glenwood Rd, Decatur, GA
(404) 284-6414
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
225
Certified beds
Average residents
201
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1967-02-17
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
RN hours / resident day
0.50
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.71
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
81%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
13,568
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.73% · Performance 22.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.08
Baseline 6.16% · Performance 7.51% · Measure score 1.08 · Achievement 1.08 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.36 hours · Performance 2.61 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.11% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 18.87% · Lower 95% interval 7.96% |
| Discharge to community | 39.94% |
50.57%
10.6 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 26.09% · Lower 95% interval 23.16% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 75% |
95.27%
20.3 pts worse
|
Numerator 18 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 214 |
| Staff flu vaccination coverage | 3.05% |
42%
39 pts worse
|
Numerator 8 · Denominator 262 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.2% |
91.2%
23 pts worse
|
93.4%
25.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.3% · Q2 67.6% · Q3 77.2% · Q4 79.7% · 4Q avg 68.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.8% |
95.0%
15.2 pts worse
|
95.5%
15.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.2%
2.2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.5% · Q3 0.5% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.8% |
9.6%
35.2 pts worse
|
11.4%
33.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.4% · Q2 37.2% · Q3 40.4% · Q4 52.7% · 4Q avg 44.8% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
5.9%
4.2 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 12.0% · Q3 13.6% · Q4 7.0% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
20.7%
1.5 pts worse
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 18.8% · Q3 25.9% · Q4 23.5% · 4Q avg 22.2% |
| 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 | 37.2% |
17.9%
19.3 pts worse
|
16.3%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 33.0% · Q3 48.4% · Q4 41.5% · 4Q avg 37.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
16.2%
0.8 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 10.0% · Q3 24.7% · Q4 17.6% · 4Q avg 15.4% · 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 0.7% · Q2 2.0% · Q3 1.2% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.0% · Q4 2.1% · 4Q avg 1.2% · 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 19.9% · Q2 22.5% · Q3 29.9% · Q4 19.4% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.2%
0.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.6% · Q3 6.4% · Q4 5.5% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.0% |
80.4%
26.4 pts worse
|
81.7%
27.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 52.7% · Q3 69.9% · Q4 63.5% · 4Q avg 54.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
12.2%
2 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 17.6% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.2%
0.8 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.8% |
78.2%
22.4 pts worse
|
79.7%
23.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.3% |
24.2%
13.1 pts worse
|
23.9%
13.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.3% · Observed 47.1% · Expected 30.1% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Rights (5 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-02
Fire Safety
Construct fire resistant interior walls.
Corrected 2026-02-02
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-02
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-05
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-05
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-05
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-05
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-12-05
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-05
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-05
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-12-05
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-05
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-12-05
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-12-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-23
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-02
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-02
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-02
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-02-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-02
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-04
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-04
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-05
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-05
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 2024-12-05
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-05
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-05
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-05
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-12-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-05
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 2024-12-05
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-05
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-05
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-04-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-08-11
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 2023-06-23
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-23
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-23
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 2023-06-23
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-06-23
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-06-23
Penalties and ownership
Fine · fine $6,521
Fine
Fine · fine $6,522
Fine
Payment Denial · denial start 2024-11-30 · 5 days
5 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
Decatur, GA
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Decatur, GA
1-star overall rating with 1-star inspections with $53,565 in total fines with 14 recent health deficiencies
Decatur, GA
3-star overall rating with 3-star inspections with 2 recent health deficiencies
Jump out