LENBROOK

3747 PEACHTREE ROAD, NE, ATLANTA, GA 30319 (404) 233-3000
Non profit - Corporation 60 Beds Independent Data: November 2025
Trust Grade
90/100
#19 of 353 in GA
Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Lenbrook nursing home in Atlanta, Georgia, has received a Trust Grade of A, indicating it is an excellent choice for care. Ranking #19 out of 353 facilities in the state places it in the top half, while being #1 of 18 in DeKalb County shows it is the best local option available. The facility is new with only two issues found during its first inspection, suggesting a stable trend without significant problems. Staffing is a strong point with a 5/5 rating and a turnover rate of 38%, lower than the state average, indicating that staff are familiar with the residents. However, there are some concerns, including a failure to properly clean or replace a nasal cannula for a resident, which could increase infection risk, and a lack of stop dates for psychotropic medications for two residents, potentially leading to unnecessary medication use. Overall, while Lenbrook has many strengths, families should be aware of these specific issues.

Trust Score
A
90/100
In Georgia
#19/353
Top 5%
Safety Record
Low Risk
No red flags
Inspections
Too New
0 → 2 violations
Staff Stability
○ Average
38% turnover. Near Georgia's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Georgia facilities.
Skilled Nurses
✓ Good
Each resident gets 55 minutes of Registered Nurse (RN) attention daily — more than average for Georgia. RNs are trained to catch health problems early.
Violations
✓ Good
Only 2 deficiencies on record. Cleaner than most facilities. Minor issues only.
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★★
5.0
Inspection Score
Stable
: 0 issues
2025: 2 issues

The Good

  • 5-Star Staffing Rating · Excellent nurse staffing levels
  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (38%)

    10 points below Georgia average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 38%

Near Georgia avg (46%)

Typical for the industry

The Ugly 2 deficiencies on record

Jan 2025 2 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Departmental Respiratory Ther...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Departmental Respiratory Therapy - Prevention of Infection, the facility failed to prevent the spread of infections by not replacing or cleaning a nasal cannula for one of five residents (R) (R9) requiring oxygen therapy. This failure had the potential to increase the risk for infection and medical complications. Findings include: Review of the facility's undated policy titled Departmental Respiratory Therapy - Prevention of Infection, under the section titled Purpose revealed, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Under the section titled Infection Control Considerations Related to Oxygen Administration revealed, 8. Keep oxygen cannulae and tubing used PRN in a plastic bag when not in use. Review of the Electronic Medical Record (EMR) for R9's medical record revealed diagnoses that included but were not limited to dementia, chronic rhinitis, shortness of breath, chronic obstructive pulmonary disease (COPD), and hypoxemia. Review of R9's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment; Section O (Special Treatments and Programs), received oxygen therapy while a resident. Observation on 1/17/2025 at 10:45 am revealed R9 in bed not wearing her nasal cannula. The nasal cannula was observed unbagged and lying on the floor. Certified Nursing Assistant (CNA) JJ retrieved the nasal cannula from the floor and placed it back in R9's nose without cleaning or replacing it. Observation on 1/17/2025 at 11:25 am revealed CNA HH entered the room, observed the situation, and reminded CNA JJ that any equipment that falls on the floor must be discarded and replaced. CNA JJ acknowledged the mistake and notified Licensed Practical Nurse (LPN) II. LPN II then replaced the nasal cannula with a new one and reminded CNA JJ of the importance of following infection control protocols. Interview on 1/17/2025 at 11:30 am with CNA JJ stated, I know the protocol is to discard equipment that falls on the floor, but I didn't replace it right away. Interview on 1/17/2025 at 11:35 am with LPN II stated, Respiratory equipment must be replaced immediately if contaminated to prevent infections. The nasal cannula was replaced as soon as I was informed of the issue. Interview on 1/17/2025 at 12:00 pm with the Director of Nursing (DON) stated, All respiratory equipment must be discarded if it comes into contact with non-sterile surfaces, as contamination can lead to respiratory infections. This is the expectation for all staff.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on staff interviews, record review, and review of the facility's policy titled Psychotropic Medication Use, the facility failed to ensure a stop date was implemented, not to exceed 14 days for p...

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Based on staff interviews, record review, and review of the facility's policy titled Psychotropic Medication Use, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two of five residents (R) (R7 and R21) reviewed for unnecessary medications. Findings include: A review of the facility policy titled Psychotropic Medication Use, dated July 2022, under the section titled, Policy Interpretation and Implementation revealed, 12. (a.) PRN (as-needed) orders for psychotropic medications are limited to 14 days. 1. A review of R7's clinical records revealed, diagnoses that included but not limited to personal history of mental and behavioral disorders and agitation. A review of R7's physician orders dated 12/17/2024 revealed, an order for lorazepam (an antianxiety medication) 0.5 milligram (mg) via (by way of) transdermal (absorbed through skin) every six hours, as needed (PRN) for agitation. The order had no stop date. A review of the Medication Administration Record (MAR) revealed, R7 was administered lorazepam 0.5 mg via transdermal on 12/23/2024 at 10:00 am, 12/23/2024 at 4:00 pm, 12/28/2024 at 8:00 am, 12/28/2024 at 5:00 pm, 12/29/2024 at 8:00 am, 12/31/2024 at 5:00 pm, 1/5/2025 at 9:00 pm, 1/6/2025 at 3:00 am, 1/7/2025 at 8:00 am, and 1/9/2025 at 9:00 am. 2. A review of R21's clinical records revealed, a diagnosis that included but not limited to anxiety. A review of R21's physician orders dated 11/9/2024 revealed, an order for lorazepam 0.5 mg by mouth (PO)/sublingual (SL) every four hours PRN for anxiety. The order had no stop date. A review of the Medication Administration Record (MAR) revealed the staff administered R21 0.5 mg of lorazepam by mouth (PO)/sublingual (SL) on 11/9/2024 at 9:05 pm, 11/13/2024 at 9:15 pm, 11/14/2024 at 11:00 pm, 11/15/2024 at 12:00 am, 11/126/2024 at 7:58 pm, and 12/22/2024 at 10:00 pm. During an interview on 1/17/2025 at 12:50 pm with the Licensed Practical Nurse (LPN) AA revealed that she audited all charts to ensure that a 14-day stop date was applied to all psychotropic medications ordered for the residents. LPN AA confirmed no 14-day stop date for R21's lorazepam, which she stated was an oversight. During an interview on 1/18/2025 at 4:03 pm with the Director of Nursing (DON) revealed, that she expected all psychotropic medications to have a 14-day stop date unless otherwise indicated by the MD. The DON acknowledged that there was no 14-day stop on R21's and R7's lorazepam, and she stated it was an oversight.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade A (90/100). Above average facility, better than most options in Georgia.
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Georgia facilities.
  • • Only 2 deficiencies on record. Cleaner than most facilities. Minor issues only.
Concerns
  • • No significant concerns identified. This facility shows no red flags across CMS ratings, staff turnover, or federal penalties.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Lenbrook's CMS Rating?

CMS assigns LENBROOK an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Georgia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Lenbrook Staffed?

CMS rates LENBROOK's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 38%, compared to the Georgia average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Lenbrook?

State health inspectors documented 2 deficiencies at LENBROOK during 2025. These included: 2 with potential for harm.

Who Owns and Operates Lenbrook?

LENBROOK is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 47 residents (about 78% occupancy), it is a smaller facility located in ATLANTA, Georgia.

How Does Lenbrook Compare to Other Georgia Nursing Homes?

Compared to the 100 nursing homes in Georgia, LENBROOK's overall rating (5 stars) is above the state average of 2.6, staff turnover (38%) is near the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.

What Should Families Ask When Visiting Lenbrook?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Lenbrook Safe?

Based on CMS inspection data, LENBROOK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Georgia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Lenbrook Stick Around?

LENBROOK has a staff turnover rate of 38%, which is about average for Georgia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Lenbrook Ever Fined?

LENBROOK has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Lenbrook on Any Federal Watch List?

LENBROOK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.