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Willowbrooke Court at Lanier Village Estates
4145 Misty Morning Way, Gainesville, GA 30506 · CMS Certification Number (CCN) 115687
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At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 8 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 0 from complaints)
- Fire safety citations
- 4
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- September 21, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Georgia average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.7 | 3 |
| Health inspections | ★★★★★ 5 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★★ 5 of 5 | 2.3 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 2.9 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | September 21, 2025 | 1 | 1 | 0 |
| Cycle 2 | April 28, 2024 | 4 | 4 | 0 |
CMS weighted health inspection score: 7 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
8 health citations across 3 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
September 21, 2025: 1 citation (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/21/2025 |
April 28, 2024: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/12/2024 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/12/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/12/2024 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/12/2024 |
February 12, 2023: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2023 |
| D | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2023 |
| D | F-0758 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
4 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 09/21/2025 | E | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/24/2025 |
| 09/21/2025 | D | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/24/2025 |
| 04/28/2024 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/12/2024 |
| 02/12/2023 | D | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/29/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Georgia average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.24 | 3.56 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.69 | 0.5 | 0.69 |
| LPN/LVN hours per resident per day | 0.95 | Not published | Not published |
| Nurse aide hours per resident per day | 2.6 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 4 | Not published | Not published |
| RN hours per resident per day, weekends | 0.41 | Not published | Not published |
| Total nursing staff turnover (%) | 23.1 | 46 | 45.8 |
| Registered nurse turnover (%) | 20 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Acts Retirement-Life Communities INC
- Ownership type
- Non profit - Corporation
- Chain
- Acts Retirement-Life Communities (27 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 48
- Average residents per day
- 43.7
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- October 5, 2003
- County/parish
- Hall
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
54 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| ACTS ACQUISITION AND DEVELOPMENT COMPANY LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS ALLIANCE MANAGEMENT LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS COMMUNITIES OF MARYLAND, INC. | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS LEGACY FOUNDATION, INC. | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT SERVICES, INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS SIGNATURE COMMUNITY SERVICES INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BONITA SPRINGS RETIREMENT VILLAGE INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MEASE LIFE INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ALLMOND, SUSAN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BROD, KATHRYN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CALLAWAY, WARREN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHAMBERLAIN, LINDA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DETWEILER, HAROLD | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ESTERHAI, JOHN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GERNER, ELRIC | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GLYNN, JAMES | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GREER, JASON | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KELLY, MICHAEL | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAMMERS, JOHN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAWSON, DANIEL | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MASHNER, MARVIN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MIDDLEBROOKS, DANIEL | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| REICHARD, DAWN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| AHERN, SUSAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ALLMOND, SUSAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, GLENN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GERNER, ELRIC | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAWSON, DANIEL | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MASHNER, MARVIN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ACTS MANAGEMENT SERVICES, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AHERN, SUSAN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, GLENN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ACTS MANAGEMENT SERVICES, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BAKER TILLY ADVISORY GROUP LP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BAKER TILLY US LLP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| U.S. BANK | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AHERN, SUSAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHRISTIANSEN, KAREN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, GLENN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GRANT, GERALD | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MOSSADED, ELLIS | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STITH, TAMEY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Willowbrooke Court at Lanier Village Estates. Full inspection reports, quality measures and staffing.
- HFR online complaint form. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.