Willowbrooke Court at Lanier Village Estates
4145 Misty Morning Way, Gainesville, GA 30506 · Hall County · (678) 450-3005
48 certified beds, about 44 residents a day · Non profit - Corporation · Medicare and Medicaid since 2003
CMS high performing icon Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
5 of 5
Staffing
5 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 115687 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 21, 2025, inspectors cited 1 health deficiency (the Georgia average is 5, the national average 9.2).
None of its 8 health citations since February 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.24 hours per resident per day, against 3.56 across Georgia and 3.86 nationally. Registered nurses accounted for 0.69 of those hours.
23.1% of nursing staff left within the year CMS measured (Georgia average 46.0%).
CMS links it to Acts Retirement-Life Communities, an affiliated group of 27 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
302/23
404/24
109/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
0B
0C
September 21, 2025Standard inspection · 1 citation
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Guidelines for Isolation Precautions, the facility failed to follow Enhanced Barrier Precautions (EBP) for two of four residents (R) (R6 and R8) on EBP while providing high-contact care. This deficient practice had the potential to increase the spread of infection due to cross-contamination.
April 28, 2024Standard inspection · 4 citations
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to implement interventions for oxygen therapy for one of seven residents (R) (R290) receiving oxygen therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Person Centered, Interdisciplinary Care Planning and Care Conference, and Catheter Care, Indwelling, the facility failed to develop a person-centered care plan with interventions that addressed performing catheter care for one of three residents (R) (R24) with an indwelling urinary catheter. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Catheter Care, Indwelling, the facility failed to assess one out of three residents (R) (R24) with an indwelling urinary catheter for self-performance of catheter care prior to allowing the resident to perform catheter care without staff direct assistance.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Oxygen Administration/Safety and Use and Care of Equipment, the facility failed to follow physician's order for oxygen therapy and failed to ensure the oxygen concentrator had a filter while in use for one out of seven residents (R) (R290) who receive oxygen via the concentrator.
February 12, 2023Standard inspection · 3 citations
- E Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interviews, and review of facility policy titled, Personal Food in Willowbrooke Court the facility failed to ensure that a policy regarding resident personal food included procedure for safe consumption/safe reheating to prevent food borne illness. The deficient practice had the potential to affect 60 of 60 residents receiving an oral diet.
- D 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.
Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Psychotropic Medications, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one Resident (R) (R#28) reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as needed (PRN) for R#28. Findings Include: A review of the medical record revealed that R#28 was admitted to the facility with a past medical history of right femur fracture, hypokalemia, dementia with behaviors, HTN, heart disease, CHF, and abdominal aortic aneurysm. [...]
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and review of facility policy titled, Holding Hot and Cold Potentially Hazardous Foods the facility failed to maintain hot food items on the portable steam table above 135 degrees to prevent food borne illness. This deficient practice affected 10 of 14 residents on the Reflections Hall consuming a regular textured diet.
Fire safety inspections
4 fire safety citations on file: 2 on September 21, 2025, 1 on April 28, 2024, 1 on February 12, 2023.
Every fire safety citation4 citations
- E Have approved installation, maintenance and testing program for fire alarm systems.
- D Install a fire alarm system that can be heard throughout the facility.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Install an approved automatic sprinkler system.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Georgia | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.24 | 3.56 | 3.86 |
| Registered nurses | 0.69 | 0.50 | 0.69 |
| All nursing staff on weekends | 4.00 | 3.10 | 3.42 |
| Nurse aides | 2.60 | ||
| Licensed practical nurses | 0.95 | ||
| Nursing staff turnover (share who left in a year) | 23.1% | 46.0% | 45.8% |
| Registered nurse turnover | 20.0% | 44.5% | 42.9% |
| Administrators who left | 0 |
CMS expects 2.90 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.34 on weekdays and 4.00 on weekends, 8% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.62 in April to June 2025 to 4.24 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.24 | 0.69 | 4.34 | 4.00 | 0.0% | 0 of 90 | 44 |
| Oct to Dec 2025 | 4.56 | 0.84 | 4.68 | 4.25 | 0.0% | 0 of 92 | 41 |
| Jul to Sep 2025 | 4.60 | 0.89 | 4.73 | 4.26 | 0.0% | 0 of 92 | 37 |
| Apr to Jun 2025 | 4.62 | 0.98 | 4.76 | 4.28 | 0.0% | 0 of 91 | 41 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Georgia, Jan to Mar 2026 | 3.50 | 0.46 | 3.68 | 3.03 | 3.3% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Georgia | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 3.5 | 15.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.5 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.7 | 2.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 9.9 | 3.2 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.3 | 2.6 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 6.8 | 15.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.1 | 5.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.5 | 19.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 32.0 | 25.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.0 | 11.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.9 | 1.8 |
Owners and operators
Legal business name: ACTS RETIREMENT-LIFE COMMUNITIES INC. CMS links this home to Acts Retirement-Life Communities, a group of 27 nursing homes averaging 4.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Acts Acquisition and Development Company LLC | Indirect ownership interest | Organization | 01/01/2003 | |
| Acts Alliance Management LLC | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Communities of Maryland, Inc. | Indirect ownership interest | Organization | 04/01/2019 | |
| Acts Legacy Foundation, Inc. | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Retirement Services, Inc | Indirect ownership interest | Organization | 03/24/2009 | |
| Acts Retirement-Life Communities Management, LLC | Indirect ownership interest | Organization | 12/31/2022 | |
| Acts Signature Community Services Inc | Indirect ownership interest | Organization | 12/31/2022 | |
| Bonita Springs Retirement Village Inc | Indirect ownership interest | Organization | 11/01/2024 | |
| Mease Life Inc | Indirect ownership interest | Organization | 10/01/2023 | |
| Acts Retirement-Life Communities Inc | 5% or greater mortgage interest | Organization | 08/01/2012 | |
| Allmond, Susan | Corporate director | Individual | 01/01/2015 | |
| Brod, Kathryn | Corporate director | Individual | 02/15/2024 | |
| Callaway, Warren | Corporate director | Individual | 03/30/2022 | |
| Chamberlain, Linda | Corporate director | Individual | 01/01/2025 | |
| Christiansen, Karen | Corporate director | Individual | 01/01/2020 | |
| Detweiler, Harold | Corporate director | Individual | 11/01/2009 | |
| Esterhai, John | Corporate director | Individual | 05/01/1996 | |
| Gerner, Elric | Corporate director | Individual | 04/01/2009 | |
| Glynn, James | Corporate director | Individual | 01/01/2023 | |
| Grant, Gerald | Corporate director | Individual | 05/04/2017 | |
| Greer, Jason | Corporate director | Individual | 03/30/2022 | |
| Kelly, Michael | Corporate director | Individual | 02/11/2020 | |
| Lammers, John | Corporate director | Individual | 12/15/2020 | |
| Lawson, Daniel | Corporate director | Individual | 06/11/2019 | |
| Mashner, Marvin | Corporate director | Individual | 01/01/1991 | |
| Middlebrooks, Daniel | Corporate director | Individual | 01/01/2023 | |
| Reichard, Dawn | Corporate director | Individual | 06/01/2025 | |
| Ahern, Susan | Corporate officer | Individual | 01/01/2020 | |
| Allmond, Susan | Corporate officer | Individual | 01/01/2025 | |
| Christiansen, Karen | Corporate officer | Individual | 05/25/2010 | |
| Fox, Glenn | Corporate officer | Individual | 01/01/2017 | |
| Gerner, Elric | Corporate officer | Individual | 01/01/2010 | |
| Grant, Gerald | Corporate officer | Individual | 05/04/2017 | |
| Lawson, Daniel | Corporate officer | Individual | 01/01/2025 | |
| Mashner, Marvin | Corporate officer | Individual | 01/01/2025 | |
| Acts Management Services, Inc. | Operational/managerial control | Organization | 01/01/2012 | |
| Acts Retirement-Life Communities Inc | Operational/managerial control | Organization | 08/01/2012 | |
| Acts Retirement-Life Communities Management, LLC | Operational/managerial control | Organization | 12/31/2022 | |
| Ahern, Susan | Operational/managerial control | Individual | 01/01/2020 | |
| Christiansen, Karen | Operational/managerial control | Individual | 05/25/2010 | |
| Fox, Glenn | Operational/managerial control | Individual | 01/01/2017 | |
| Grant, Gerald | Operational/managerial control | Individual | 06/01/2005 | |
| Acts Management Services, Inc. | Adp of the SNF | Organization | 07/23/2025 | |
| Acts Retirement-Life Communities Inc | Adp of the SNF | Organization | 08/01/2012 | |
| Acts Retirement-Life Communities Management, LLC | Adp of the SNF | Organization | 07/23/2025 | |
| Baker Tilly Advisory Group LP | Adp of the SNF | Organization | 02/03/2025 | |
| Baker Tilly Us LLP | Adp of the SNF | Organization | 11/05/2024 | |
| U.s. Bank | Adp of the SNF | Organization | 07/09/2025 | |
| Ahern, Susan | Adp of the SNF | Individual | 01/01/2020 | |
| Christiansen, Karen | Adp of the SNF | Individual | 05/25/2010 | |
| Fox, Glenn | Adp of the SNF | Individual | 01/01/2017 | |
| Grant, Gerald | Adp of the SNF | Individual | 06/01/2005 | |
| Mossaded, Ellis | Adp of the SNF | Individual | 03/01/2025 | |
| Stith, Tamey | Adp of the SNF | Individual | 11/02/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on April 28, 2024: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 2 problems in this area, most recently on April 28, 2024: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 2 problems in this area, most recently on February 12, 2023: "Have a policy regarding use and storage of foods brought to residents by family and other visitors."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 1 problem in this area, most recently on September 21, 2025: "Provide and implement an infection prevention and control program."
Other nursing homes nearby
- Pruitthealth - Limestone Gainesville, 5 mi · 4 of 5 stars · 16 citations
- New Horizons Limestone Gainesville, 5.6 mi · 4 of 5 stars · 11 citations
- Bell Minor Home, the Gainesville, 6.3 mi · 1 of 5 stars · 31 citations
- Chelsey Park Health and Rehabilitation Dahlonega, 11.6 mi · 5 of 5 stars · 4 citations
- Gold City Health and Rehab Dahlonega, 12.3 mi · 1 of 5 stars · 23 citations
- Crossroads of Flowery Branch of Journey LLC, the Flowery Branch, 13.1 mi · 1 of 5 stars · 31 citations
- Gateway Health and Rehab Cleveland, 13.2 mi · 4 of 5 stars · 2 citations
- Friendship Health and Rehab Cleveland, 17.7 mi · 5 of 5 stars · 4 citations
Georgia contacts for a concern about a nursing home
These are the official offices in Georgia. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Georgia Department of Community Health, Healthcare Facility Regulation Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Georgia Long-Term Care Ombudsman Program, 1-866-552-4464. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: GaMap2Care, Find a Facility, where Georgia publishes its own records on licensed homes.
Common questions
- What is Willowbrooke Court at Lanier Village Estates's Medicare star rating?
- CMS rates Willowbrooke Court at Lanier Village Estates 5 out of 5 stars overall, with 5 for health inspections, 5 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willowbrooke Court at Lanier Village Estates get at its last inspection?
- 1 health deficiency at the standard inspection on September 21, 2025. The Georgia average is 5.
- Has Willowbrooke Court at Lanier Village Estates been fined?
- CMS lists no fines in the last three years.
- Does Willowbrooke Court at Lanier Village Estates accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Willowbrooke Court at Lanier Village Estates?
- CMS lists 54 owners and managers, and links the home to Acts Retirement-Life Communities. Legal business name: ACTS RETIREMENT-LIFE COMMUNITIES INC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.