01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-21 | 1 | 2025-09-21 | 2 |
| Cycle 2 | 2024-04-28 | 4 | 2024-04-28 | 1 |
| Cycle 3 | 2023-02-12 | 3 | 2023-02-12 | 1 |
CMS CCN 1156872026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willowbrooke Court At Lanier Village Estates
4145 Misty Morning Way · Gainesville, GA 30506 · Hall County
Certified beds48CMS provider file
Recent citation rows12current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
12 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 0 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-21 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-212025-09-21 · FIREK0341Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2025-11-242025-09-21 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-11-242024-04-28 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-06-122024-04-28 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-06-122024-04-28 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-06-122024-04-28 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-06-122024-04-28 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-06-122023-02-12 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-03-292023-02-12 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-03-292023-02-12 · HEALTHF0813Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Correction field: Deficient, Provider has date of correction · 2023-03-292023-02-12 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2023-03-2903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ACTS ACQUISITION AND DEVELOPMENT COMPANY LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/2003
- ACTS ALLIANCE MANAGEMENT LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS COMMUNITIES OF MARYLAND, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2019
- ACTS LEGACY FOUNDATION, INC.Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS RETIREMENT SERVICES, INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 03/24/2009
- ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- ACTS SIGNATURE COMMUNITY SERVICES INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2022
- BONITA SPRINGS RETIREMENT VILLAGE INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/01/2024
- MEASE LIFE INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2023
- ACTS RETIREMENT-LIFE COMMUNITIES INCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 08/01/2012
- ALLMOND, SUSANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- BROD, KATHRYNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/15/2024
- CALLAWAY, WARRENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/30/2022
- CHAMBERLAIN, LINDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- CHRISTIANSEN, KARENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2020
- DETWEILER, HAROLDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2009
- ESTERHAI, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/01/1996
- GERNER, ELRICIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2009
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.24per resident day
RN hours0.69per resident day
Weekend nurse hours4.00per resident day
Staff turnover23.1%CMS reported field