Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Calhoun Crossing Of Journey Llc during CMS and state inspections, most recent first.
Missing stop date for PRN psychotropic medication: A resident with a seizure disorder had a PRN lorazepam IM order for seizure activity that remained active without a required stop date. The facility policy required PRN psychotropic orders to have a set duration, and staff, including an LPN/Unit Manager and the DON, confirmed the order lacked the 14-day stop date.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in fall prevention and care planning. One resident's care plan did not address his desire for prostheses, another resident's bed was not kept in a low position as required, and a third resident fell due to inadequate staff assistance during incontinence care. These oversights were acknowledged by facility staff, highlighting a breakdown in care plan implementation.
A resident with bilateral above-the-knee amputations did not receive the necessary follow-up for prostheses fitting, despite being evaluated as ready and expressing a strong desire for independence. The facility failed to arrange the required appointments, leading to the resident's emotional distress. Interviews with staff revealed communication lapses and a lack of follow-through on the resident's care plan.
Two residents experienced falls due to inadequate supervision and failure to adhere to care plans. One resident, requiring two-person assistance, fell and was injured when a CNA provided care alone. Another resident, with a care plan requiring a low bed position, fell when the bed was not maintained in the correct position. Staff interviews confirmed these deficiencies.
The facility's QAPI plan was incomplete, lacking specific facility information and data-driven measures to address resident care and safety. The plan did not include tracking, trending, or performance measurements on clinical concerns, nor did it show feedback from staff, residents, or family members. The Administrator confirmed the plan was sourced online, potentially affecting all 91 residents.
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, preventing them or their representatives from making informed decisions about financial liabilities for services not covered by Medicare. The residents remained in the facility after their skilled services ended without receiving the necessary notices, as confirmed by the Administrator.
The facility failed to provide written notification of hospital transfers for three residents, as required by federal regulations. The deficiency was due to the absence of a policy ensuring written notices were given to residents or their representatives. This was confirmed through interviews with the Administrator and DON, who acknowledged the lack of enforcement of this requirement.
The facility failed to complete accurate PASARR assessments for two residents. One resident's PASARR was outdated, and another's inaccurately reflected their mental health diagnoses, despite documented conditions such as PTSD and major depressive disorder. The facility's policy lacked guidance on addressing inaccurate PASARRs, contributing to these deficiencies.
The facility failed to include required language in its arbitration agreements for two cognitively intact residents, indicating that signing was not mandatory for admission or continued care. The Business Office Manager confirmed the omission during an interview, revealing a lack of awareness of this requirement.
The facility failed to provide timely access to personal funds for three residents due to restricted banking hours, limited to weekdays from 9:00 AM to 3:00 PM. Residents expressed a desire for weekend access, which was previously available but had been discontinued. Interviews with staff confirmed the lack of access outside these hours, despite the Administrator's expectation for reasonable access.
The facility failed to provide quarterly financial statements to two residents, one cognitively intact and one mildly impaired, whose funds were managed by the facility. The Medical Records Director sent statements to resident representatives instead, contrary to the Administrator's expectation for capable residents to receive their own statements.
The facility failed to release funds from Personal Needs (PN) Accounts to residents or their Responsible Parties (RP) within the federally mandated 30 days after discharge. This deficiency affected three residents who had passed away, with balances remaining in their accounts for several months. Interviews with facility staff confirmed the oversight, with no clear explanation provided for the delay.
The facility failed to provide written notification of its Bed Hold Policy to residents or their representatives prior to hospital transfers. Three residents were hospitalized without documented evidence that the policy was communicated in writing, despite the facility's policy requiring it. The administrator confirmed the absence of documentation, indicating non-compliance with the policy.
A facility failed to refer a resident for a Level II PASARR evaluation after a new diagnosis of major depressive disorder. Despite the facility's policy requiring such referrals for newly evident serious mental disorders, no PASARR Level II was submitted following the diagnosis. The resident was initially admitted without this diagnosis, but later evaluations and care plans indicated the presence of major depressive disorder and the use of antidepressant medication.
A resident receiving enteral nutrition via a PEG tube had their feeding bag improperly labeled, lacking essential information such as date, time, and resident's name. The LPN on duty confirmed the oversight, attributing it to the night shift nurse. Interviews revealed a lack of accountability and adherence to the facility's policy, which mandates proper labeling for safety and compliance with clinical standards.
Two residents with Type 2 Diabetes experienced medication administration errors involving insulin pens, resulting in a 6.06% error rate. One LPN failed to leave the needle in the skin for the required time, while another did not prime the pen needle before administration. Both actions were contrary to the facility's insulin policy.
The facility failed to maintain effective infection control for two residents. One resident, COVID-19 positive, was not properly isolated as staff entered without PPE, despite clear droplet precaution signage. Another resident's catheter tubing was observed on the floor, risking infection. The facility's policies on isolation and catheter care were not followed, leading to these deficiencies.
The facility failed to administer pneumococcal vaccines according to CDC guidelines for two residents over the age of 65. One resident received the PCV15 vaccine but was not offered the PPSV23 within the recommended timeframe, while another received the PPSV23 but was not offered the PCV15 or PCV20. The RN responsible did not transfer the due dates to her tracking log, leading to the oversight. The interim IP and DON were unaware of these lapses, and the Administrator expected timely vaccine administration.
Missing stop date for PRN psychotropic medication
Penalty
Summary
The facility failed to ensure a stop date was implemented, not to exceed 14 days, for a psychotropic medication ordered for one resident. The resident had an order dated 10/23/2025 for lorazepam injection solution 2 mg/ml to be given intramuscularly every 12 hours as needed, and the order did not include a stop date. A review of the facility policy titled Use of Psychotropic Medication(s), dated 03/20/2025, stated that PRN psychotropic medication orders require a specified duration over 14 days with a clinical rationale and cannot be renewed for longer than 14 days without a direct evaluation by the prescriber. A pharmacist consultation report dated 12/22/2025 noted that the resident had an order for lorazepam 20 mg, administered as 2 mg/ml intramuscularly every 12 hours as needed for seizure activity, and that the order had been in effect for more than 14 days without a specified stop date. The pharmacist recommended discontinuing the PRN lorazepam or, if discontinuation was not possible, documenting the indication, intended duration, and rationale for extended use. During interviews, an LPN and Unit Manager stated that a 14-day stop date is required for psychotropic medications but confirmed that this resident did not have one, and the DON acknowledged that the resident's PRN lorazepam did not have the required stop date.
Deficiencies in Care Planning and Fall Prevention
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to deficiencies in fall prevention and care planning. For one resident with bilateral above-the-knee amputations, the care plan did not address his desire for bilateral prostheses and independence with ambulation, despite his goal to return home. The facility's care plan only focused on coping skills for limb loss, neglecting the resident's expressed wishes. Another resident, diagnosed with Alzheimer's Disease and severely cognitively impaired, was at risk for falls due to balance problems and lack of safety awareness. The care plan required the bed to be in the lowest position to prevent falls, but observations revealed the bed was consistently at regular height. This oversight was acknowledged by the facility's Administrator and DON, who confirmed that care plans should be followed as documented. A third resident, with hemiplegia and morbid obesity, required two-person assistance for incontinence care. However, a CNA, unaware of this requirement, attempted to provide care alone, resulting in the resident falling out of bed and sustaining a broken finger. The CNA admitted to not reviewing the care plan or receiving proper training, and the DON confirmed the fall was due to the care plan not being followed. The MDSC verified that the care plan was accessible to all CNAs, indicating a communication breakdown in care plan implementation.
Failure to Provide Prostheses for Resident with Bilateral Amputations
Penalty
Summary
The facility failed to provide appropriate adaptive equipment as directed by Physical Therapy recommendations for a resident with bilateral above-the-knee amputations. The resident, who was cognitively intact, had been admitted with diagnoses including diabetes and required supervision for bed mobility and transfers. Despite making consistent progress in physical therapy and being evaluated as ready for prostheses, the facility did not ensure the resident received the necessary follow-up appointments for fitting the prostheses. The resident had been evaluated by a Certified Prosthetist/Certified Orthotic Assistant, who confirmed the resident's readiness for bilateral prostheses. However, there was no evidence in the clinical record that a follow-up appointment was made to fit the resident with the prostheses. The resident repeatedly expressed his need for the prostheses to promote his independence, and his emotional distress was noted by staff and during interviews. Interviews with facility staff, including the Director of Rehabilitation and Nurse Practitioners, revealed a lack of communication and follow-through regarding the resident's prostheses. The facility's scheduler, responsible for arranging community appointments, was on leave, contributing to the oversight. The resident's emotional state was affected by the delay, as he was eager to regain independence and return home with the use of prostheses.
Failure to Prevent Falls Due to Inadequate Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to prevent a fall for two residents, R10 and R47, resulting in harm to R10. R10, who was moderately cognitively impaired and required assistance from two staff members for incontinence care, fell off the bed when a CNA provided care alone. The CNA was unaware of the two-person assistance requirement and did not review R10's care plan. This resulted in R10 suffering a closed head injury, a laceration to the forehead, and a fracture of the fifth finger on the right hand. R47, who was severely cognitively impaired and required assistance for transfers, experienced an unwitnessed fall while attempting to transfer from bed to wheelchair. The care plan for R47 included keeping the bed in the lowest position to prevent falls. However, observations revealed that the bed was not consistently kept in the low position, and there was no sign to remind staff of this requirement. The failure to maintain the bed in the correct position contributed to the fall. Interviews with staff and family members confirmed the deficiencies in following care plans for both residents. The CNA involved in R10's care was not informed of the two-person assistance requirement, and the staff responsible for R47's care did not ensure the bed was kept in the low position. The facility's policies on fall prevention and adherence to care plans were not effectively implemented, leading to these incidents.
Incomplete QAPI Plan Lacks Data-Driven Measures
Penalty
Summary
The facility failed to develop a comprehensive Quality Assurance Performance Improvement (QAPI) plan that effectively addressed resident care, safety, quality of life, and resident choice. The QAPI plan, dated 2022 and prepared by Compliance Store, was intended to establish a data-driven, facility-wide program to improve the quality of care and services. However, the plan was found to be incomplete, lacking specific facility information and failing to address potential quality of care issues. Notably, the plan did not include data-driven information such as tracking and trending, or performance measurements on specific clinical concerns. Additionally, the facility's QAPI plan did not demonstrate any feedback from staff, residents, or family members regarding identified potential deficient practices. During an interview, the Administrator acknowledged presenting the QAPI plan to the survey team and confirmed that the plan was printed from an online source. This lack of a detailed and facility-specific QAPI plan had the potential to affect all 91 residents currently living in the facility.
Failure to Provide SNFABN Notices to Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, R145 and R146, which is necessary for informing them or their representatives about potential financial liabilities for services not covered by Medicare. The deficiency was identified through interviews, record reviews, and facility policy reviews. The facility's failure to issue the SNFABN prevented the residents or their representatives from making informed decisions regarding the costs of continued therapy services after the end of their skilled services. For resident R145, the facility's records indicated that skilled services ended on 08/21/24, yet the resident remained in the facility without receiving the SNFABN. Similarly, for resident R146, skilled services ended on 08/08/24, and the resident also stayed in the facility without receiving the necessary notice. During an interview, the Administrator acknowledged that the previous social services staff member was responsible for distributing the ABN notices, but confirmed that only the Notice of Medicare Non-Coverage was provided to the residents' representatives, not the SNFABN.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification regarding the reason for hospital transfers for three residents, which is a requirement under federal regulations. The facility did not have a policy in place to ensure that written notices were given to residents or their representatives when a transfer to the hospital occurred. This deficiency was confirmed through interviews with the Administrator and the Director of Nursing, who acknowledged the absence of such a policy and the lack of enforcement of the requirement. The deficiency involved three residents who were transferred to the hospital without written notification being provided to them or their responsible parties. One resident, who was severely cognitively impaired, was transferred twice due to medical issues without written notice to his representative. Another resident, experiencing altered mental status and other symptoms, was sent to the emergency room without written notification to the resident or their responsible party. Similarly, a third resident was transferred to the hospital due to a medical condition without written notice being provided. The Administrator confirmed the lack of documentation for these notifications during an interview.
Failure to Complete Accurate PASARR Assessments
Penalty
Summary
The facility failed to complete the required Pre-Admission Screening and Resident Reviews (PASARR) for two residents, leading to deficiencies in their care. For one resident, identified as R31, the PASARR Level I was dated over 30 days before the resident's admission, which did not meet the facility's expectation to complete a new PASARR if the previous one was outdated. The resident was currently receiving mental health services, indicating the need for an updated assessment. For another resident, identified as R64, the PASARR Level I inaccurately indicated the absence of a major mental illness diagnosis, despite the resident having documented diagnoses of PTSD, anxiety disorder, and major depressive disorder. The resident's care plans and physician orders reflected these conditions, and the Director of Nursing confirmed the inaccuracy of the PASARR. The facility's policy did not address the responsibility for correcting inaccurate PASARR assessments, contributing to the oversight.
Arbitration Agreement Language Deficiency
Penalty
Summary
The facility failed to include specific language in its arbitration agreement for two residents, which is a requirement to ensure that residents and their families are informed of their rights. The arbitration agreement did not explicitly state that signing the agreement was not a condition for admission or continued care at the facility. This omission was identified during a review of the facility's documents and interviews with staff. The Business Office Manager confirmed that the current admission agreement lacked the necessary language, indicating a lack of awareness of this requirement. Two residents, who were cognitively intact as indicated by their BIMS scores, signed the arbitration agreements without being informed that it was not mandatory for their admission or continued care. The residents' electronic medical records and the facility's arbitration agreements were reviewed, revealing the absence of the required language. The Business Office Manager, responsible for completing the admission packets, acknowledged the deficiency during an interview, confirming that the agreements did not contain the necessary information.
Limited Access to Resident Funds Due to Restricted Banking Hours
Penalty
Summary
The facility failed to ensure the timely availability of personal resident funds for three residents, as the banking hours were limited to Monday through Friday from 9:00 AM to 3:00 PM, with no access on weekends. This deficiency was identified through record reviews and interviews with residents and staff. Resident 3, who was moderately cognitively impaired, expressed a desire to access her funds on weekends, which was previously possible but had since been restricted. Resident 31, who was cognitively intact, also wished to access his funds daily, including weekends, but was unable to do so due to the limited banking hours. Resident 37, who was mildly cognitively impaired, wanted to access her funds on Sundays to give money to her son for purchases, but was similarly restricted by the facility's banking schedule. Interviews with the Medical Record Director and the Business Office Manager confirmed that residents could not access their personal needs accounts outside the posted banking hours. The Medical Record Director, responsible for the personal needs accounts, acknowledged the lack of access during evenings and weekends. The Business Office Manager and the Administrator confirmed this limitation, with the Administrator stating her expectation that residents should have reasonable access to their personal funds. Despite this expectation, the facility's current banking hours did not accommodate residents' needs for accessing their funds outside of the specified times.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to ensure accurate financial accounting and record retention for two residents, R31 and R37, regarding their Personal Needs Accounts. R31, who was cognitively intact with a BIMS score of 15, confirmed that the facility managed his money but did not provide him with a quarterly statement of his account. Similarly, R37, who was mildly cognitively impaired with a BIMS score of 12, also confirmed that she did not remember receiving quarterly statements for her account. The Medical Records Director acknowledged that the facility was managing funds for both residents and confirmed that neither received their quarterly statements. Instead, the statements were sent to the Resident Representative listed in each resident's record, following the director's process of sending statements to representatives regardless of the resident's cognitive ability. The Administrator stated that her expectation was for cognitively intact residents capable of understanding their finances to receive their quarterly statements.
Failure to Release Resident Funds Timely
Penalty
Summary
The facility failed to release resident funds managed in Personal Needs (PN) Accounts to the residents or their Responsible Parties (RP) within 30 days of discharge, as required by federal regulations. This deficiency was identified for three residents, each of whom had passed away in the facility. Resident R195, who had Alzheimer's Disease and respiratory failure, passed away over 13 months prior to the survey, yet still had an active PN Account with a balance of $4882.92. Similarly, Resident R197, with type 2 diabetes, passed away over four months prior, with a remaining balance of $233.00 in their PN Account. Resident R199, diagnosed with liver and colon cancers, passed away nearly seven months before the survey, leaving a balance of $170.00 in their account. Interviews with facility staff, including the Medical Records Director and the Administrator, confirmed the existence of these balances and the failure to return the funds to the respective RPs. The Medical Records Director was unable to provide an explanation for the delay in returning the funds. The Administrator acknowledged the deficiency, stating that the facility's expectation was to return funds within 30 days of discharge, in accordance with federal regulations. This oversight indicates a lapse in the facility's management of resident funds, affecting the timely conveyance of funds to the appropriate parties.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its Bed Hold Policy to residents or their representatives prior to hospital transfers, as required by its own policy. This deficiency was identified through a review of records for three residents who were hospitalized. Resident 64, who was severely cognitively impaired, was transferred to the hospital twice for medical issues, but there was no documentation indicating that his spouse, who was his representative, received the bed hold policy in writing. Similarly, Resident 70 was transferred to the hospital on two occasions due to altered mental status and lethargy, yet there was no evidence that the bed hold policy was communicated to the responsible party in writing. Additionally, Resident 94 was sent to the emergency room due to a significant drop in pulse and oxygen levels, as well as a concerning physical finding, but again, there was no documentation of the bed hold policy being provided in writing. The facility's administrator confirmed the absence of such documentation in the residents' records and acknowledged that the facility's policy was not followed. This oversight created the potential for residents and their representatives to be uninformed about their rights regarding bed hold procedures during hospital transfers.
Failure to Submit PASARR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to make a referral for a Level II Preadmission Screening and Resident Review (PASARR) evaluation for a resident who was diagnosed with major depressive disorder. The facility's policy, as outlined in a document titled 'Resident Assessment-Coordination with PASARR Program' dated 02/12/22, requires that any resident exhibiting a newly evident or possible serious mental disorder be promptly referred to the state mental health authority for a Level II resident review. Despite this policy, the facility did not submit a PASARR Level II evaluation for the resident after a psychiatric provider diagnosed them with major depressive disorder on 01/04/24. The resident, identified as R31, was admitted to the facility without a diagnosis of major depressive disorder, as indicated in a PASARR Level I document dated 05/05/23. However, a psychiatric diagnostic evaluation later identified the resident with major depressive disorder, and the resident's care plan dated 05/13/24 noted the use of antidepressant medication for this condition. Despite these developments, the facility's records did not show evidence of a PASARR Level II submission following the new diagnosis. During an interview, the Administrator confirmed that the expectation was for social services to submit a new PASARR when a new mental health diagnosis is identified.
Failure to Label Enteral Feeding Bag
Penalty
Summary
The facility failed to label an enteral feeding bag according to professional standards for a resident with a history of dysphagia following cerebral infarction and gastroparesis. The resident was receiving enteral nutrition via a PEG tube, as per physician orders, which specified the feeding schedule and rate. However, during an observation, it was noted that the feeding bag lacked essential labeling information such as the date, time started, resident's name, and initials. This omission was confirmed by the LPN on duty, who stated that the night shift nurse was responsible for hanging the bag and should have completed the label. Interviews with the nursing staff revealed a lack of clarity and accountability regarding the labeling process. The LPN who worked the night shift admitted to not checking the label, although she was assigned to the resident. The Director of Nursing confirmed that it was standard practice to complete the labels for safety reasons, as enteral feeding is only viable for 24 hours. The facility's policy and competency documents also emphasized the importance of proper labeling to ensure compliance with clinical standards and prevent complications.
Medication Administration Errors in Insulin Delivery
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.06% error rate during the survey. This deficiency was identified through the review of medication administration for two residents, both diagnosed with Type 2 Diabetes, who were receiving insulin via pen injectors. The first resident, R54, was administered insulin by an LPN who did not leave the insulin pen needle inserted in the resident's skin for the required six to ten seconds, potentially affecting the full absorption of the medication. The LPN admitted to being unaware of this requirement, which was outlined in the facility's insulin policy. The second resident, R79, was administered insulin by another LPN who failed to prime the insulin pen needle before administration, which is necessary to ensure no air is injected instead of insulin. The LPN stated she had not been instructed to prime the needle unless air was visible in the pen chamber. The Director of Nursing confirmed that the facility's policy required priming the insulin pen with two units before each administration and leaving the needle in the skin for the specified duration to ensure proper medication delivery.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program for two residents, leading to potential health risks. One resident, who was COVID-19 positive, was not properly isolated as staff failed to don personal protective equipment (PPE) before entering the resident's room. Despite clear signage indicating droplet precautions and the presence of a PPE cart outside the room, a Certified Nurse Aide (CNA) entered without wearing the necessary protective gear. The interim Infection Preventionist and the Director of Nursing acknowledged the oversight and confirmed that no recent in-services had been provided to staff regarding isolation precautions. Another deficiency was observed with a resident who had an indwelling catheter. The catheter tubing was repeatedly observed in contact with the floor, which poses a risk of infection. The resident, who had diagnoses including Down Syndrome and urinary retention, was unable to communicate effectively due to cognitive impairments. Despite multiple observations throughout the day, the catheter tubing remained on the floor, and a CNA confirmed that it should not be in contact with the floor to prevent infection. The facility's policies on transmission-based precautions and catheter care were not adhered to, as evidenced by the staff's actions and the condition of the residents' care. The Director of Nursing and the Administrator both stated their expectations for staff to follow infection control policies, yet the observed practices did not align with these expectations, leading to the identified deficiencies.
Failure to Administer Pneumococcal Vaccines Timely
Penalty
Summary
The facility failed to offer the pneumococcal vaccination in accordance with CDC guidelines for two residents, R48 and R55, who were over the age of 65. R48 was admitted to the facility and had signed a consent form to receive a pneumococcal vaccine. The resident was administered the PCV15 vaccine, but the follow-up PPSV23 vaccine was not offered or administered within the recommended timeframe of one year. This oversight occurred because the registered nurse (RN2) did not transfer the due date for the next vaccination from the consent form to her tracking log, leading to the omission. Similarly, R55 was administered the PPSV23 vaccine but was not offered the subsequent PCV15 or PCV20 vaccine within the recommended timeframe. The same RN2 was responsible for this oversight, as she failed to transfer the due date to her tracking log. The interim Infection Preventionist and the Director of Nursing were unaware of these lapses, and the Administrator expected the staff to obtain consent and administer vaccines timely. These failures had the potential to increase the risk for the residents to contract pneumonia.
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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 Calhoun
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gordon Health And Rehabilitation | 0.7 mi | ★★★★★ | 3 | 0 |
| Ridgewood Manor Health And Rehabilitation | 17 mi | ★★★★★ | 2 | 0 |
| Regency Park Health And Rehabilitation | 17.1 mi | ★★★★★ | 6 | 0 |
| Quinton Mem Hc & Rehab Center | 17.7 mi | ★★★★★ | 0 | 0 |
| Murray Woods Of Journey Llc | 18.7 mi | ★★★★★ | 22 | 0 |
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