Cycle 1
Health 2025-01-19 · Fire 2025-01-19
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Atlanta, GA
Lenbrook
5-star overall rating with 5-star inspections with 2 recent health deficiencies
3747 Peachtree Road, Ne, Atlanta, GA
(404) 233-3000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-12-20
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.56
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.80
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
6.23
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
2.43
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
5.51
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
6.76
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,255
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0136
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.45
Baseline 19.71% · Performance 20.76% · Measure score 1.45 · Achievement 1.45 · Improvement 0
Healthcare-associated infections
5.45
Baseline 6.83% · Performance 6.21% · Measure score 5.45 · Achievement 5.45 · Improvement 2.89
Total nurse turnover
6.45
Baseline 32.39% · Performance 37.33% · Measure score 6.45 · Achievement 6.45 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.03 hours · Performance 6.04 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.46% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 187 · Observed rate 10.7% · Lower 95% interval 7.64% |
| Discharge to community | 71.96% |
50.57%
21.4 pts better
|
Better than the National Rate · Eligible stays 165 · Observed rate 69.09% · Lower 95% interval 63.62% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 98 |
| Discharge self-care score | 47.62% |
53.69%
6.1 pts worse
|
Numerator 30 · Denominator 63 |
| Discharge mobility score | 52.38% |
50.94%
1.4 pts better
|
Numerator 33 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 98 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 3.7% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 27.27% |
8.2%
19.1 pts better
|
Numerator 84 · Denominator 308 |
| Staff flu vaccination coverage | 19.89% |
42%
22.1 pts worse
|
Numerator 74 · Denominator 372 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 27 · Denominator 63 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 87.5% |
25.2%
62.3 pts better
|
Numerator 42 · Denominator 48 |
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 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.0
1.2 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
91.2%
3.1 pts better
|
93.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 95.5% · Q3 94.3% · Q4 94.4% · 4Q avg 94.3% |
| 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 | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.3% · Q3 5.7% · Q4 5.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
9.6%
8.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.9%
4.9 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.6% |
20.7%
12.9 pts worse
|
19.6%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 25.8% · Q3 30.8% · Q4 40.7% · 4Q avg 33.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
21.4%
6.1 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 18.2% · Q3 9.5% · Q4 18.2% · 4Q avg 15.3% · 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 | 9.1% |
17.9%
8.8 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
16.2%
1.1 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.7% · Q3 29.2% · Q4 22.7% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.5%
2 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.7% · Q3 8.6% · Q4 2.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
16.1%
3.9 pts worse
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 15.9% · Q3 8.6% · Q4 20.2% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
6.2%
3.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 6.2% · Q3 1.8% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
80.4%
12.3 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 96.0% · Q3 94.1% · Q4 84.0% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
12.2%
6.5 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 5.1% · Expected 9.9% · 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% · Q4 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 | 93.7% |
78.2%
15.5 pts better
|
79.7%
14 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
24.2%
2.5 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 24.1% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
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 2022-03-24 · Fire 2022-03-24
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2025-01-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-19
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 2025-02-21
Penalties and ownership
What sits behind the stars
Ownership
Dove, Leslie
Corporate Officer · Individual
Graves, Tara
W-2 Managing Employee · Individual
Keysor, Christopher
Corporate Officer · Individual
Kill, Mark
Corporate Director · Individual
Wells Fargo Bank, National Association
5% Or Greater Mortgage Interest · Organization
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