Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Cartersville Crossing Of Journey Llc during CMS and state inspections, most recent first.
Food Served Was Bland and Unappetizing Residents reported that meals were consistently bland, tasteless, watery, cold, or inconsistent, including chicken noodle soup, vegetables, mashed potatoes, meat, and other lunch items. A test tray was also tasted by the RD, DD, and DM, who agreed the meatloaf, carrots, green beans, and chicken noodle soup lacked flavor or had poor texture. The RD stated the kitchen followed cycle menu recipes and preparation instructions designed for a heart healthy diet.
QAPI committee failed to include required members at a quarterly meeting. The facility policy required the QAA Committee to include the DON, Medical Director or designee, at least three other staff members with at least one leader, and the Infection Preventionist. Review of the sign-in sheet showed the Administrator and Medical Director were absent, and the Administrator confirmed the meeting proceeded without them and neither attended in person nor by phone.
The facility failed to provide complete transfer and bed hold notices for four residents who were emergently sent to the hospital/ER after acute changes in condition, including chest pain, a fall with a swollen wrist, a critically low Hgb, and SOB. The SNF/NF transfer forms did not include appeal rights or the State LTC Ombudsman mailing address, and the bed hold notices did not show whether the resident or RR received them.
A resident’s quarterly MDS did not document hospice services. The resident’s record showed diagnoses including metabolic encephalopathy and senile degeneration of the brain, and a physician order indicated hospice admission. The Administrator stated the MDS was improperly coded and did not reflect the resident as receiving hospice services.
The facility failed to maintain cleanliness in the kitchen and adhere to food safety protocols. Unclean kitchen equipment, undated and moldy bread products, and improperly stored food items were observed. Expired and undated food items were also found in a resident refrigerator, with the responsibility for monitoring assigned to night shift nursing staff.
The facility failed to provide transfer notifications to two residents or their representatives during hospital transfers, as required by policy. One resident, moderately impaired, was transferred for chest pain without a bed hold form, while another, severely impaired, was sent for evaluation without a written notice. The Social Services Director was unaware of the requirement to provide transfer forms.
The facility failed to provide bed hold notices to two residents during hospital transfers, as required by policy. One resident, moderately cognitively impaired, and another, severely impaired, were transferred without receiving the necessary documentation. The Social Services Director confirmed the oversight, indicating a lack of awareness of the requirement.
A resident with severe protein-calorie malnutrition experienced significant unplanned weight loss due to the facility's failure to obtain an admission weight and perform re-weights as required. The facility's CRD was not informed of the weight changes, leading to a lack of timely evaluation and intervention. This oversight placed the resident at risk for further health complications.
A resident with moderate cognitive impairment and edentulous condition was not provided food in a form that met her needs, despite her requests for yogurt and inability to chew hard fruits like cantaloupe. The facility's policy required food to be provided in the appropriate form, but this was not consistently followed, leading to the resident's dietary needs not being met.
Food Served Was Bland, Watery, and Lacked Flavor
Penalty
Summary
The facility failed to ensure food served to residents was palatable for seven of seven residents reviewed for food palatability, including R10, R24, R39, R7, R58, R46, and R29. Review of the facility policy titled, Menus and Adequate Nutrition, showed the menus were to reflect input from residents and resident groups. Interviews with cognitively intact residents R10, R24, R39, R7, R46, and R29, and moderately cognitively impaired R58, showed repeated complaints that meals were bland, tasteless, watery, cold, or inconsistent. R10 said chicken noodle soup was always cold and tasteless and that all meals needed improvement. R24 said some meals tasted good and others did not. R39 said meals were tasteless and bland. R7 said the vegetables were bland and the mashed potatoes watery. R58 said the vegetables tasted bland. R46 said the hot foods on the lunch tray tasted warm. R29 said the meat and vegetables were bland and required salt and pepper. On the requested test tray, the Registered Dietitian, Dietary Director, and Dietary Manager observed and tasted the food after the tray left the kitchen and after the last resident was served. They agreed the meatloaf lacked flavor and taste, the carrots were soggy, watery, and lacked flavor, the green beans were mushy and tasteless, and the chicken noodle soup lacked flavor and taste. During interview, the RD stated the kitchen followed the food distribution company cycle menu recipes and preparation instructions, and that the cycle menus were heart healthy and restricted salt, butter, and oils. The RD also stated the facility required the menus to be followed to provide residents with a heart healthy diet.
QAPI Committee Missing Required Members at Quarterly Meeting
Penalty
Summary
The facility's QAPI committee failed to ensure the required members attended the quarterly meeting. Review of the facility policy showed the QAA Committee was required to be interdisciplinary and include, at a minimum, the DON, the Medical Director or designee, at least three other staff members with at least one in a leadership role such as the Administrator, and the Infection Preventionist. However, review of the sign-in sheet for the first quarter 2025 QAPI meeting dated 02/19/25 showed the Administrator and Medical Director were not present. During interview, the Administrator stated the Interim Administrator at that time and the Medical Director were not available, so the meeting went ahead anyway, and neither attended physically nor by phone, which is why there were no signatures for them on the sign-in sheet.
Missing transfer appeal and bed hold notices
Penalty
Summary
The facility failed to ensure that residents and/or their Resident Representatives received the required written transfer notice and bed hold notice after emergent transfers to the hospital for four of 47 sampled residents. Review of the facility’s policy showed that transfer/discharge notices were to include an explanation of the right to appeal the transfer or discharge, information on how to obtain an appeal form, assistance with completing and submitting the appeal request, and the mailing address of the Office of the State Long-Term Care Ombudsman. The policy also stated that, for emergency transfers to acute care, the resident and representative were to be provided a notice of transfer and the facility’s bed hold notice policy. For R6, R7, R38, and R3, record review showed each resident had an emergent transfer to the hospital or ER after acute changes in condition, including chest pain and shortness of breath, a fall with a swollen and misshapen wrist, a critically low hemoglobin result, and shortness of breath requiring ER evaluation. The facility’s SNF/NF to Hospital Transfer Forms for each resident failed to include how to appeal the transfer and the mailing address of the Ombudsman. In addition, the bed hold notices for R7, R38, and R3 did not document whether the resident or RR received the notice, and the Administrator could not provide evidence that R6’s resident or RR received the bed hold notice. During interview, the Administrator stated there was no evidence on the transfer notice of appeal rights, the Ombudsman’s mailing address, or that the resident or RR received the bed hold notice.
MDS Did Not Reflect Hospice Status
Penalty
Summary
Resident 80’s quarterly MDS assessment with an ARD of 12/23/25 did not document that the resident was receiving hospice services. Review of the resident’s admission record showed diagnoses including metabolic encephalopathy and senile degeneration of the brain, and review of a physician order showed the resident was admitted to hospice care effective 03/19/26. During interview, the Administrator stated the MDS was improperly coded and did not reflect the resident as receiving hospice services.
Deficiencies in Kitchen Cleanliness and Food Safety Protocols
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in its kitchen and resident food storage areas. During an inspection, it was observed that the kitchen's convection oven, two conventional ovens, stove top spill pan, and a large manual can opener were unclean with accumulated food spills and residues. The Dietary Aide confirmed these areas had not been cleaned as per the weekly schedule, which had been neglected for about three weeks. Additionally, the facility did not adhere to proper food labeling and storage protocols. In the kitchen's dry storage, several packages of bread products were found without use-by or expiration dates, and some were moldy. In the walk-in refrigerator, nutritional shakes were stored without thaw dates, and in the walk-in freezer, food items were left open and unprotected. The Regional Registered Dietitian confirmed that the nutritional shakes should have been dated and discarded if not used within 14 days. In the resident refrigerator on the 300 hallway, several food items were found to be expired or improperly stored. Freezer-burnt grapes and watermelon with an expired date were found in the freezer compartment, while expired yogurts and undated nutritional shakes were found in the refrigerator section. The Regional Director of Environmental Service confirmed these findings and discarded the items. The Director of Nursing stated that it was the night shift nursing staff's responsibility to monitor the food stored in the resident refrigerator.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely notification to two residents or their responsible parties regarding hospital transfers, as well as failing to notify the long-term care ombudsman. This deficiency was identified through staff interviews, record reviews, and a review of the facility's policy on transfer and discharge. The policy requires that a notice of transfer and the facility's bed hold policy be provided to the resident or representative during emergency transfers initiated for medical reasons. However, this procedure was not followed for two residents, R9 and R24, out of a sample of 19. Resident R9, who was moderately impaired in cognition, was transferred to a hospital for tingling in her left arm and chest pain, but there was no documentation of a bed hold form being provided. Similarly, Resident R24, who was severely cognitively impaired, was transferred to a hospital for evaluation after new orders were received, but no written transfer notice was provided to the resident or their representative. The Social Services Director confirmed that no transfer forms were provided during such transfers and was unaware of this requirement in the facility's policy.
Failure to Provide Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to issue a bed hold notice to two residents or their responsible parties during transfers to the hospital, as required by their policy. The policy, implemented on 02/01/22, mandates that at the time of transfer for hospitalization or therapeutic leave, the facility must provide written notice to the resident or their representative, specifying the duration of the bed-hold policy and information about the resident's return to the next available bed. However, this procedure was not followed for two residents, R9 and R24, during their respective transfers. Resident R9, who was moderately impaired in cognition, was transferred on 07/17/24 for medical reasons, but no bed hold notice was documented in her electronic medical record. Similarly, Resident R24, who was severely cognitively impaired, was transferred to the hospital on 08/30/24, and there was no documentation of a bed hold notice being provided. The Social Services Director confirmed that no bed hold notices were issued to these residents upon their transfers, indicating a lack of awareness of this requirement.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of a resident, identified as R17, who experienced significant unplanned weight loss. Upon admission, the facility did not obtain an initial weight for R17 within the required 24-hour period, as per their Weight Monitoring Program policy. The first documented weight was not recorded until several days later, and subsequent significant weight losses were not re-weighed or addressed in a timely manner. This oversight led to a lack of evaluation and intervention by the facility's Consultant Registered Dietitian (CRD) and the Interdisciplinary Team. R17 was admitted with severe protein-calorie malnutrition, a fractured femur, and anxiety disorder, placing her at high risk for nutritional issues. Despite these conditions, the facility did not follow its policy to monitor weight changes effectively. The CRD was unaware of the significant weight loss due to a lack of communication and documentation from the staff. The resident's weight dropped from 159 pounds to 122 pounds over a short period, indicating a 23.27 percent weight loss, which was not addressed until much later. Interviews with staff, including the CRD, Registered Nurse Supervisor, MDS Coordinator, and Director of Nursing, revealed a breakdown in communication and procedure adherence. The CRD was not informed of the weight changes, and the MDS Coordinator could not verify the source of the initial weight documented. The Director of Nursing acknowledged the failure to obtain an admission weight and the lack of re-weighing after significant weight loss. These failures in protocol placed R17 at risk for further health complications due to inadequate nutritional management.
Failure to Provide Appropriate Food Form for Edentulous Resident
Penalty
Summary
The facility failed to provide food in a form that met the needs of a resident, identified as R14, who was edentulous and had requested specific dietary accommodations. R14, who had moderate cognitive impairment and was at risk for nutritional issues due to her lack of teeth, had requested to receive yogurt at meals because it was easy for her to eat. Despite this request, the facility did not consistently provide yogurt on her meal trays, and she was served hard fruits like cantaloupe, which she could not chew. R14's care plan indicated she was selective about her food and required food preferences to be provided as available. However, observations revealed that R14 was not served yogurt with her meals on multiple occasions, and she was served cantaloupe, which she could not eat due to her edentulous condition. The facility's policy on Therapeutic Diet Orders required that residents receive food in the appropriate form as prescribed by the physician or assessed by the interdisciplinary team, but this was not adhered to in R14's case. Interviews with the Certified Nurse Aide (CNA) and the Consultant Registered Dietitian (CRD) confirmed that R14 should not have been served hard fruits and should have received yogurt as requested. The CRD acknowledged the oversight and noted that R14 had been referred to Speech Therapy for evaluation due to her difficulty chewing certain foods. Despite these acknowledgments, the facility's failure to provide the appropriate food form persisted, as observed over several days.
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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 Cartersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cartersville Center For Nursing And Healing | 1.2 mi | ★★★★★ | 5 | 0 |
| Townsend Park Health And Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Chulio Hills Health And Rehab | 15.4 mi | ★★★★★ | 12 | 0 |
| Ross Memorial Health Care Ctr | 15.5 mi | ★★★★★ | 0 | 0 |
| Woodstock Center For Nursing And Healing Llc | 16.8 mi | ★★★★★ | 11 | 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.