Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WILLOWBROOKE COURT AT LANIER VILLAGE ESTATES

GAINESVILLE, GA · 48 certified beds · Last Life Safety survey September 21, 2025

CMS Certification Number 115687 · first certified October 2003

Ownership

Operated by ACTS RETIREMENT-LIFE COMMUNITIES · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

4
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
2
Inspection & testing records
Of the citations on file

Position within GA

4 citations — more than 17% of the 356 certified nursing homes in GA. Compared within GA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was September 2025. Facilities in GA are typically surveyed 14–20 months after the last one (median 16), measured over 532 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Physical environment (health survey)

1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 4 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in GA, and nationally. Surveyors differ markedly between states, so the GA figure is the meaningful one.

This facility4GA median8National median11
Citations on file over three years, compared
MeasureCitations
This facility4
Median facility in GA8
Median facility nationally11

Survey history

Citations at each Life Safety survey
12023-0212024-0422025-09
Citations at each Life Safety survey
Survey dateCitations
February 12, 20231
April 28, 20241
September 21, 20252

Most-cited tags

Most-cited tags at this facility
K-03511K-03451K-03531K-03411
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0351Install an approved automatic sprinkler system.12023-02-12
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12025-09-21
K-0353Inspect, test, and maintain automatic sprinkler systems.12024-04-28
K-0341Install a fire alarm system that can be heard throughout the facility.12025-09-21

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies4

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 21, 2025 — 2 citations

Citations issued on September 21, 2025
TagWhat the surveyor checksStatus
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (November 24, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (November 24, 2025)

April 28, 2024 — 1 citation

Citations issued on April 28, 2024
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 12, 2024)

February 12, 2023 — 1 citation

Citations issued on February 12, 2023
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (March 29, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.