Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Abbeville Crossing Of Journey Llc during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a need for supervision was given hot ramen noodles by a CNA without an assessment of their ability to handle hot liquids. The resident transported the noodles on their lap, spilled them, and sustained a burn injury. Staff had not received training on reheating food or checking temperatures, and no assessment for hot liquid safety had been completed prior to the incident.
Three residents with documented behavioral symptoms, such as wandering, aggression, and inappropriate public behavior, were not accurately coded for these behaviors on their MDS assessments. Staff responsible for MDS coding relied on verbal reports and did not review clinical progress notes, resulting in incomplete and inaccurate behavioral documentation.
A resident with severe cognitive impairment and multiple diagnoses was identified as at risk for elopement, but the care plan only included redirection as needed and placement of the resident's photo in the elopement book, lacking specific interventions for supervision or monitoring. The resident subsequently eloped and was found deceased. Interviews confirmed that no additional individualized interventions were documented or implemented.
A resident with severe cognitive impairment and a known risk for elopement was able to exit the facility through an unlocked kitchen door after staff failed to conduct required rounds and secure the area. The resident accessed the kitchen, turned on the oven, and left the building unsupervised, later being found deceased off facility grounds. Additionally, the steam table in the dining room was left on and unsupervised with residents present, creating a significant burn hazard.
A resident with a history of neurocognitive and psychiatric disorders, identified as at risk for elopement, was able to exit the facility after a staff member left a kitchen door unlocked. The resident was not noticed missing for several hours, and was later found deceased outside the facility. The facility failed to secure the environment, accurately assess and code wandering behavior, and implement care plan interventions to address elopement risk.
Resident Burned by Hot Food Due to Lack of Assessment and Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a need for supervision with activities of daily living was given a bowl of hot ramen noodles by a CNA, without an assessment of the resident's ability to safely handle hot liquids. The resident, who had diagnoses including bipolar disorder, difficulty walking, and weakness, received the hot noodles and was allowed to transport them on his lap down the hallway to his room. The resident subsequently spilled the hot noodles on his upper left thigh, resulting in a burn with a blister and surrounding redness. Facility policy required that reheated foods be cooled to a palatable temperature before consumption to prevent burns, and that all residents be assessed for their ability to handle hot liquids, with individualized care plans as needed. However, review of the clinical record showed no evidence that such an assessment had been completed for this resident prior to the incident. Staff interviews confirmed that no training had been provided on reheating food, taking food temperatures, or assessing residents' ability to handle hot liquids before the incident occurred. Multiple staff members, including CNAs, LPNs, RNs, and the Infection Preventionist, reported not having received training on reheating food or checking temperatures. The administrator and dietary manager also confirmed that residents had not been assessed for hot liquid safety prior to the incident. The lack of assessment and supervision directly led to the resident sustaining a burn injury from the hot noodles.
Failure to Accurately Assess and Code Behavioral Symptoms on MDS
Penalty
Summary
The facility failed to accurately assess and code behavioral symptoms on the Minimum Data Set (MDS) for three residents out of a sample of fourteen. According to the facility's policy, assessments are to be completed by qualified staff and must reflect the resident's status at the time of assessment. However, documentation in the clinical records showed that residents exhibited various behavioral symptoms, including wandering, agitation, aggression, undressing in public areas, and combative behavior during care, which were not properly coded in section E of their respective MDS assessments. For one resident, progress notes documented repeated wandering, entering other residents' rooms, agitation when redirected, undressing in hallways, eating off other residents' plates, and urinating on the dining room floor. Despite these documented behaviors, the quarterly MDS assessment did not reflect these physical and wandering behaviors. Another resident's records showed incidents of smearing fecal matter, urinating in the hallway, taking another resident's clothing, yelling loudly, and expressing self-harm, but these behaviors were also not coded in the MDS. A third resident was noted to be combative during incontinence care and dressing, yet this was not captured in the annual MDS assessment. Interviews with staff revealed that the Social Services Director, responsible for completing the behavior section of the MDS, did not review resident progress notes as part of her information-gathering process. Instead, she relied on verbal reports and staff meetings. This omission contributed to the failure to accurately code behavioral symptoms, as the documented behaviors in the clinical records were not consistently reflected in the MDS assessments.
Failure to Develop and Implement Comprehensive Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with appropriate interventions for a resident identified as being at risk for elopement. Despite the resident having a care plan in place for elopement risk, the only interventions documented were to redirect the resident as needed and to add the resident's picture to the elopement book. There were no specific interventions addressing supervision, monitoring, or management of the resident's elopement risk, as required by facility policy and professional standards of quality. The resident in question had multiple diagnoses, including anemia, glaucoma, mild neurocognitive disorder with behavioral disturbance, Alzheimer's disease, and psychotic disorder with delusions. The resident's most recent assessment indicated severely impaired cognition and a need for supervision with transfers and ambulation. An elopement evaluation had been completed, scoring the resident as at risk for elopement, yet the care plan did not reflect individualized or adequate interventions to address this risk. On the date of the incident, the resident was found missing during staff rounds, prompting an immediate search of the facility and notification of the administrator, DON, and local police. The resident was later found deceased outside the facility. Interviews with the DON confirmed that the only interventions in the care plan were the resident's picture in the elopement book and redirection as needed, and that if interventions were not documented, they were not considered done. This lack of comprehensive, individualized interventions in the care plan constituted noncompliance with requirements for resident safety and care planning.
Failure to Prevent Elopement and Supervise Accident Hazards
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with severe cognitive impairment and a known risk for elopement. The resident, who had diagnoses including Alzheimer's disease, mild neurocognitive disorder, and psychotic disorder, was assessed as being at risk for elopement. Despite this, the only interventions in place were to redirect the resident as needed and to include the resident's picture in an elopement book. The resident's care plan did not include more robust interventions, and staff failed to conduct required two-hourly rounds as expected by facility policy. On the night of the incident, a kitchen door that should have been locked was left unsecured by dietary staff, allowing the resident to access the kitchen and subsequently exit the building. Video surveillance showed the resident entering the kitchen, turning on the oven, and eventually leaving the facility through the unlocked kitchen door. The resident was not accounted for during staff rounds, and there was confusion among staff regarding the last time the resident was seen. The resident was later found deceased off facility grounds. Additionally, the facility failed to supervise hazardous equipment, as the steam table in the dining room was left on and unsupervised with residents present. The steam table contained hot water at temperatures up to 160 degrees Fahrenheit and was accessible to residents, posing a significant burn risk. Staff interviews confirmed that the responsibility for turning off the steam table was not clearly followed, and the equipment was left on after meal service without supervision.
Failure to Prevent Resident Elopement Due to Inadequate Environmental Oversight
Penalty
Summary
Facility administration failed to provide adequate monitoring and protective oversight of the environment, resulting in a resident's elopement and subsequent death. The Executive Director and Director of Nursing did not ensure that the kitchen entry door was locked, which allowed the resident to access the kitchen and exit the building. The last dietary staff member on duty left the kitchen door unlocked, and the resident was able to walk through the kitchen and leave the facility undetected. The resident involved had multiple diagnoses, including anemia, glaucoma, mild neurocognitive disorder with behavioral disturbance, Alzheimer's disease, and psychotic disorder with delusions. An elopement evaluation had been completed, indicating the resident was at risk for elopement. Despite this, the facility failed to accurately assess and code the resident's wandering behavior on the Minimum Data Set (MDS) and did not develop or implement care plan interventions to address the resident's risk of elopement. Staff did not notice the resident was missing for at least four hours after the elopement occurred. The resident was last seen by a CNA late at night, and there was confusion among staff about the last time the resident was observed. The failure to secure the kitchen door and lack of timely resident monitoring contributed directly to the resident's ability to leave the facility without detection, ultimately resulting in the resident being found deceased outside the facility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Abbeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crossview Care Center | 13.8 mi | ★★★★★ | 7 | 0 |
| Heart Of Georgia Nursing Home | 15.3 mi | ★★★★★ | 7 | 0 |
| Eastman Trails Of Journey Llc | 17.2 mi | ★★★★★ | 11 | 0 |
| Pruitthealth - Fitzgerald | 18.5 mi | ★★★★★ | 4 | 0 |
| Harmony Health And Rehabilitation | 19.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.