Cycle 1
Health 2025-05-07 · Fire 2025-05-07
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Decatur, GA
Harborview Decatur
3-star overall rating with 3-star inspections with $6,292 in total fines with 10 recent health deficiencies
2787 North Decatur Road, Decatur, GA
(404) 292-0626
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
73
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1976-09-01
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
0.88
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.02
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,250
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.59
Baseline 21.12% · Performance 19.30% · Measure score 4.59 · Achievement 4.59 · Improvement 3.94
Healthcare-associated infections
6.35
Baseline 7.55% · Performance 5.94% · Measure score 6.35 · Achievement 6.35 · Improvement 5.82
Total nurse turnover
0
Performance 70.91% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.29 hours · Performance 2.59 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.45% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 14.61% · Lower 95% interval 8.07% |
| Discharge to community | 50.53% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 97 · Observed rate 40.21% · Lower 95% interval 39.97% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 7.14% |
2.29%
4.8 pts worse
|
Numerator 2 · Denominator 28 · Adjusted rate 5.59% |
| Healthcare-associated infections requiring hospitalization | 5.94% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 0% · Lower 95% interval 2.99% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 3 · Denominator 66 |
| Staff flu vaccination coverage | 8% |
42%
34 pts worse
|
Numerator 6 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · 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 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.5% |
91.2%
9.7 pts worse
|
93.4%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 90.4% · Q3 75.0% · Q4 63.3% · 4Q avg 81.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 72.8% |
9.6%
63.2 pts worse
|
11.4%
61.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 72.1% · Q3 73.2% · Q4 65.9% · 4Q avg 72.8% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.9%
3.7 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.2% · Q3 7.9% · Q4 20.5% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.8% |
20.7%
16.9 pts better
|
19.6%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.0% · Q3 4.9% · Q4 2.2% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
21.4%
1.7 pts better
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 19.4% · Q3 25.8% · Q4 20.7% · 4Q avg 19.7% · 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 | 53.6% |
17.9%
35.7 pts worse
|
16.3%
37.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 53.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.2% |
16.2%
10 pts worse
|
14.9%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 28.3% · Q3 28.9% · Q4 12.2% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.1%
0.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.5%
1.1 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 2.0% · Q3 2.4% · Q4 2.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.2% |
16.1%
0.1 pts worse
|
19.8%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 22.3% · Q3 10.3% · Q4 16.1% · 4Q avg 16.2% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
6.2%
5.3 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 16.2% · Q3 13.3% · Q4 6.9% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 30.8% |
80.4%
49.6 pts worse
|
81.7%
50.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 57.7% · Q2 45.1% · Q3 21.9% · Q4 10.7% · 4Q avg 30.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.2% |
12.2%
5 pts worse
|
12.0%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 17.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.2%
1.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.1% |
78.2%
31.1 pts worse
|
79.7%
32.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
24.2%
3.7 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 21.6% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-08 · Fire 2023-06-08
3 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-11-10 · Fire 2021-11-10
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-07
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
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 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F657 · Resident Assessment and Care Planning Deficiencies
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 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-09
E · Potential for more than minimal harm
2023-06-08
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-08
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 2023-07-20
D · Potential for more than minimal harm
2021-11-10
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-12-25
Penalties and ownership
What sits behind the stars
$2,098
2024-01-02
Fine
Fine · fine $2,098
Fine
$4,194
2023-12-11
Fine
Fine · fine $4,194
Fine
Ownership
Ga Nc 14, LLC
5% Or Greater Direct Ownership Interest · Organization
Cl 2022 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
De 2021 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Englander, David
Corporate Officer · Individual
Leibowitz, Chaim
Corporate Officer · Individual
Thomas, Lizzie
W-2 Managing Employee · Individual
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#3
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