Below 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 Crossroads Of Flowery Branch Of Journey Llc, The during CMS and state inspections, most recent first.
Resident trust funds were not secured by a surety bond large enough to cover the total account balance. The BOM stated she handled individual resident cash but did not monitor the full account balance, and the President of Operations confirmed the trust fund balance exceeded the $75,000 bond. The Administrator stated the balance should not exceed the bond amount.
Incomplete and Unimplemented Comprehensive Care Plans: The facility failed to develop and implement comprehensive care plans that reflected residents’ diagnoses, treatments, and care needs. A resident with nephrostomy tubes had no nephrostomy care in the care plan, a resident with pressure ulcers and an order for pressure-relieving boots was observed without the boots in place, a resident with alcohol-related diagnoses had no alcohol-related focus, a resident with diabetes did not receive insulin before breakfast as ordered, and two residents had care plans that omitted key assistance and anticoagulant-related needs. The DON confirmed the care plans were not up to date or fully followed.
Resident Not Included in Care Plan Conference: A cognitively intact resident with multiple diagnoses, including bilateral lower-extremity amputations, blindness, depression, anxiety, and DM2, was not shown to have participated in development of his person-centered care plan. The EMR had no documentation of a care plan conference or refusal, and the resident stated he had never had one and would like to attend. Staff could not locate documentation of the conference.
Advance Directive Status Not Consistently Documented: The facility failed to keep code status documentation consistent for two residents. Both records showed FULL CODE physician orders and medical summaries, while the care plans and POLST forms reflected DNR/Allow Natural Death directives signed by the residents and the physician. The DON confirmed the EMRs were not updated consistently with the new code status.
Failure to Develop Baseline Care Plans Within 48 Hours: The facility did not complete baseline care plans for three residents within the required timeframe. One resident had orders for PT/INR labs, anticoagulation observation, and skilled OT, another had diagnoses including BKA, DM2 with foot ulcer, ESRD, and dialysis dependence, and a third had nephrostomy tubes with related diagnoses including sepsis, AKI, CKD, and bladder cancer. The DON confirmed the missing care plans in the EMR.
A resident with diabetes was not given ordered insulin before meals on multiple occasions, with staff confirming the insulin was missed or delayed. Another resident’s ordered PT/INR lab was not completed and no result was found in the EMR. A third resident with a chronic ulcer did not receive daily wound care as ordered, and the wound dressing was observed dated several days earlier; staff gave inconsistent accounts of who was responsible for completing the treatment.
A resident with respiratory failure and COPD did not receive ordered nocturnal O2 because the facility had not provided an O2 concentrator after admission, and the resident reported waking with headache and dyspnea. Another resident with respiratory failure, OSA, and chronic bronchitis had no BiPAP order initially, and surveyors observed the BiPAP mask uncovered and unbagged on the nightstand before the order was added. The DNS confirmed the delayed O2 setup and that BiPAP equipment should be bagged.
Dialysis Communication and Documentation Deficiencies: The facility failed to ensure that a resident receiving hemodialysis had care and services managed in accordance with professional standards, including ongoing communication with the dialysis center. The EMR lacked communication records, staff were unsure about the process for sending the resident to dialysis and documenting exchanges, and the DON/DNS confirmed there was no daily dialysis communication documentation in the chart. The resident had an AV fistula and a standing dialysis schedule, but the record also lacked dialysis orders and did not identify the resident as a dialysis patient on the admission skin assessment.
Two residents with significant medical conditions, including dementia and heart failure, made allegations of staff-to-resident abuse that were reported to facility staff but not reported to administration or the State Survey Agency within the required timeframe. Facility staff, including the DON and SSD, failed to document, report, or investigate these allegations as required by policy, resulting in a lack of appropriate response to the reported incidents.
The facility did not properly identify or investigate allegations of staff-to-resident abuse for two residents. In one case, a resident with dementia and on hospice care reported being hurt by staff, but no investigation was conducted. In another case, a cognitively intact resident was found with bruising, but the investigation lacked interviews with the resident and other residents, and there was no analysis of the cause or staff training on abuse reporting.
Two residents experienced significant weight loss that was not accurately coded in their MDS assessments. One resident with dysphagia lost over 8% of body weight, and another with Parkinson's disease lost over 13% in a month, but these losses were not documented in the MDS. Staff interviews confirmed the omissions, and the DON acknowledged the expectation for accurate MDS coding.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility failed to ensure that two CNAs completed the required in-service training hours, with CNA AA completing only 5.5 out of 6 hours and CNA FF completing 1.15 out of 12 hours. This deficiency was identified during a staff development review. Interviews revealed a lack of awareness and oversight, with management collectively responsible for overseeing in-services but no designated person for the task. The ADON and CNA AA were unaware of the non-compliance, while the DON expected all CNAs to complete their in-service hours to ensure resident safety.
The facility failed to document and communicate resolutions to resident concerns voiced during Resident Council meetings. Despite the policy requiring follow-up, the Activity Director and DON acknowledged that resolutions were not documented, leaving residents unaware of outcomes or grievance procedures.
The facility failed to maintain a safe and homelike environment, with six resident rooms having furniture in disrepair and leaking PTACs. Dressers in several rooms were missing drawers or knobs, and PTACs in other rooms leaked water onto the floors. The Maintenance Director confirmed these issues, citing extreme heat and condensation as causes for the PTAC leaks, and noted challenges in addressing these problems due to working alone.
CNAs in the facility failed to use hand sanitizer between distributing lunch trays to residents, despite being reminded by an RN. The CNAs admitted to forgetting the practice and had not received handwashing training since starting at the facility. The DON confirmed the expectation for proper hand hygiene to prevent infection control issues.
A resident with multiple chronic conditions experienced a significant change in condition, including altered mental status and respiratory distress, leading to transfer to the ED. Despite assessments and actions taken by nursing staff and a nurse practitioner, there was no timely documentation of the change of condition or the events leading to the transfer in the medical record, nurses' notes, 24-hour report, or SBAR report. The deficiency was only identified after surveyor inquiry, prompting late entries.
Resident Trust Fund Balance Exceeded Surety Bond
Penalty
Summary
The facility failed to ensure the security of resident personal funds deposited with the facility because the surety bond was not maintained in an amount sufficient to cover the total balance of the resident trust account. A review of the State of Georgia Department of Community Health Long-Term Care Facility Residents' Fund Bond dated 11/1/2024 showed a surety bond of $75,000.00, while the resident trust fund balance was documented at $89,766.98 on 8/31/2025 and remained above the bond amount in September 2025, including balances of $92,763.98, $92,399.48, $92,176.43, $92,006.43, $81,289.91, $77,745.31, $75,463.05, $75,603.05, and $75,214.29. During interview, the BOM stated she was responsible for giving residents cash and was not sure what a surety bond is. She also stated she only handles individual resident trust funds and does not look at the whole balance of the account. The President of Operations confirmed the BOM oversees the total amount of the resident trust fund account and acknowledged that the amount from August 2025 to September 2025 was over the $75,000 surety bond. The Administrator stated his expectation was that the resident trust fund balance should not exceed the surety bond and that the bond should be increased if it does.
Incomplete and Unimplemented Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that reflected residents’ medical, nursing, physical, mental, and psychosocial needs for six sampled residents. The facility policy stated that comprehensive care plans were to be developed within seven days after completion of the comprehensive MDS assessment and revised after each comprehensive and quarterly MDS assessment. Review of records, observations, and interviews showed that the care plans for these residents did not include required diagnoses, treatments, risk factors, or specific care needs, and in some cases the documented interventions were not being followed. R90 was admitted and later re-admitted with diagnoses including displacement of a nephrostomy catheter, malignant neoplasm of the bladder, gram-negative sepsis, acute cystitis with hematuria, acute kidney failure, and chronic kidney disease stage 3. His admission MDS showed a BIMS of 7, indicating severe cognitive impairment. During observation, he was in bed with two urinary bags attached to nephrostomy tubes, including cloudy dark yellow drainage in one bag. RN AA confirmed the nephrostomy tubes, but the most recent comprehensive care plan did not mention nephrostomy care. The DNS confirmed there was no order for dressing changes or care orders for the nephrostomy tubes and that the care plan was not up to date to reflect care for the nephrostomy tube sites. R12 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle weakness, contracture, stage 2 pressure ulcer of the sacral region, stage 4 pressure ulcer of the left heel, and contracture of the left hand. His quarterly MDS showed a BIMS of 1, indicating severe cognitive impairment. His care plan included wound-related interventions and an order for prevalon boots, but observations on two occasions showed he had no pressure-relieving boots on. The Unit Manager confirmed the boots were not on but should have been, and the DNS confirmed that if the care plan included pressure-relieving boots, they should have been in place. R74 had diagnoses including alcohol abuse, depression, insomnia, and unspecified mood affective disorder, and had multiple psychotropic medication orders. Her care plan did not include any focus or interventions related to alcohol diagnosis or alcohol-related risk factors. R1 had diagnoses including bilateral lower-extremity amputations, legal blindness, and type 2 diabetes, with an insulin order requiring administration before breakfast. He reported that insulin was sometimes given after meals, and on one morning he was observed eating breakfast before receiving insulin. The LPN confirmed insulin had not been given before breakfast that day, and the DNS confirmed the diabetes care plan interventions tied to the physician orders were not followed. R57 had diagnoses including cerebral infarction and hemiplegia/hemiparesis following cerebrovascular disease, and his quarterly MDS showed a BIMS of 12. His care plan contained only full code and discharge focuses, with no indication of the level of assistance needed or mention of clopidogrel use for blood clot prevention. R16 had diagnoses including a displaced fracture of the right fibula, head injury, and generalized anxiety disorder, and had an order for apixaban twice daily. Her care plan did not include any focus or interventions related to anticoagulant medication administration. The DNS confirmed that R57 and R16 should have had more complete care plans that included these needs and risk factors.
Resident Not Included in Care Plan Conference
Penalty
Summary
The facility failed to allow one resident to participate in the development of his person-centered plan of care. The resident had multiple diagnoses, including acquired absence of the left leg below the knee, acquired absence of the right leg above the knee, obesity, insomnia, legal blindness, major depressive disorder, anxiety disorder, and type 2 diabetes. His quarterly MDS showed a BIMS score of 15, indicating he was cognitively intact. The facility policy stated that the care planning process would include the resident's strengths, needs, personal and cultural preferences, and that the comprehensive care plan would include the resident and the resident's representative, to the extent practicable. The resident's care plan included a focus on being resistive to care and occasionally refusing medications related to resident choice, with interventions that allowed him to make decisions about the treatment regimen and provided opportunities for choice during care. However, the EMR contained no documentation showing that he attended or refused to attend the development of the comprehensive care plan. During interview, the resident stated he had never had a care plan conference, did not know what it was, and said he would like to attend one. Facility staff stated care plan conferences were typically held after admission, quarterly, annually, or upon request, but they could not locate documentation of a care plan conference for the resident.
Advance Directive Status Not Consistently Documented
Penalty
Summary
The facility failed to ensure that advance directive status was consistently documented in the clinical record for two sampled residents, R16 and R112. A review of the facility policy titled Residents' Rights Regarding Treatment and Advance Directives stated that any decision making regarding a resident's choices must be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. The survey found that both residents had conflicting documentation in their EMRs regarding code status and advance directives. R16's record showed an active physician order for FULL CODE STATUS and the medical summary also listed FULL CODE, while the care plan identified Advanced Directives Do Not Attempt Resuscitation (DNR). The EMR also contained a POLST form indicating Allow Natural Death and Do Not Attempt Resuscitation, signed by R16 and the physician. R112's record similarly showed an active physician order for FULL CODE STATUS and the medical summary listed FULL CODE, while the care plan identified Advanced Directives Do Not Attempt Resuscitation (DNR). R112's EMR also contained a POLST form indicating Allow Natural Death and Do Not Attempt Resuscitation, signed by R112 and the physician. The DNS confirmed that R16's and R112's EMRs were not updated consistently with the new code DNR.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop a Baseline Care Plan within 48 hours of admission for three of 46 sampled residents: R14, R109, and R90. The facility policy titled Baseline Care Plan, implemented on 2/1/2024, stated that the baseline care plan must be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy orders, and social services, with a supervising nurse verifying that it had been completed within 48 hours. A review of R14’s EMR showed physician orders for PT/INR labs, anticoagulation medication observation, and skilled OT, but no baseline or comprehensive care plan was present. During interview, the DNS confirmed that residents should have a baseline care plan within 48 hours of admission and acknowledged that no care plan was in the EMR for R14. R109’s EMR showed admission with diagnoses including acquired absence of the right leg below the knee, type 2 diabetes mellitus with foot ulcer, dependence on renal dialysis, and end-stage renal disease, but no baseline or comprehensive care plan was documented. The DNS confirmed during interview that no baseline care plan or comprehensive care plan had been completed for R109. R90 was admitted and later readmitted with diagnoses including displacement of nephrostomy catheter, malignant neoplasm of bladder, gram-negative sepsis, acute cystitis with hematuria, acute kidney failure, and chronic kidney disease stage 3. During observation, R90 had two urinary bags attached to nephrostomy tubes, with cloudy dark yellow fluid in one bag and clear yellow fluid in the other. RN AA confirmed that R90 had nephrostomy tubes, and the EMR contained no baseline care plan upon admission related to the nephrostomy. The DNS confirmed that no baseline care plan had been completed for R90 to reflect care for the nephrostomy tube sites.
Failure to Follow Orders for Insulin, Lab Testing, and Wound Care
Penalty
Summary
The facility failed to follow physician orders for insulin administration for a resident with type 2 diabetes, legal blindness, and bilateral lower-extremity amputations. The resident’s orders required Humulin insulin before breakfast, before lunch, and before dinner. The resident, who had a BIMS score of 15, stated on multiple occasions that insulin was not being offered before meals and that he had reminded staff about it. During observation, he was eating breakfast before receiving insulin, and the Unit Manager confirmed that the ordered insulin had not been given before breakfast. An LPN later confirmed that the resident had not been offered or administered insulin before breakfast and stated she had technical difficulties with her computer when she arrived on shift. The DNS confirmed the physician orders were not followed. The facility also failed to complete an ordered PT/INR blood test for a resident with diagnoses including type 2 diabetes, endocarditis, and a femur fracture with orthopedic aftercare. The physician order required next-day PT/INR labs one time daily every month starting on the 15th. During record review and interview, the DNS confirmed that the PT/INR blood test ordered for the resident was not completed and that there were no test results in the EMR. She was not able to explain why the blood test was not done. In addition, the facility failed to complete daily wound care for a resident with a non-pressure chronic ulcer and intact cognition. The resident’s care plan and TAR indicated that wound care was to be performed daily. During observation, the resident’s wound dressing was dated several days earlier, indicating the dressing had not been changed as ordered. Staff interviews showed confusion and inconsistency about responsibility for wound care, with one LPN stating nursing staff were sometimes overwhelmed and unable to complete ordered wound care, another LPN stating the Unit Manager was responsible for checking the TAR, and the Unit Manager and DON stating the floor nurse was responsible for completing wound care and should seek help if overwhelmed.
Missing respiratory therapy orders and improper BiPAP storage
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy for one resident and for BiPAP for another resident. The facility policy titled Oxygen Administration stated that personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists, and the policy titled Medication Orders addressed verification of written transfer orders when needed. The deficiency involved residents receiving respiratory support without the required physician orders being in place at the time of the survey observations and record review. One resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD with acute exacerbation, and shortness of breath. The resident’s record contained oxygen orders dated after admission for oxygen at night during sleep at 2 L/min and later 4 L/min via nasal cannula. The hospital discharge summary documented acute respiratory failure secondary to influenza A and COPD exacerbation, and noted the resident had been weaned off oxygen during the day but continued to require oxygen at night. The resident stated she was supposed to sleep with oxygen but had not been provided an oxygen concentrator for a couple of nights since admission, and reported waking at 3:00 a.m. with a headache and difficulty breathing. The DNS stated the oxygen order started on the day of admission and that the delay occurred because staff did not bring the oxygen concentrator at admission. Another resident was admitted with diagnoses including acute respiratory failure with hypoxia, obstructive sleep apnea, simple chronic bronchitis, and shortness of breath, and had a BIMS score of 10 indicating moderate cognitive impairment. A review of physician orders printed on one date showed no BiPAP orders, while orders printed the next day documented BiPAP settings and that the resident was to wear BiPAP at night with vital signs and oxygen saturation documented before use. The resident’s hospital paperwork documented that the patient required BiPAP and high-flow oxygen for respiratory distress and increased work of breathing. During observations, the resident’s BiPAP mask was found uncovered and unbagged on the nightstand, and the resident stated he used it every night. The Unit Manager confirmed the mask should be placed in a bag, and the DNS stated BiPAP masks and tubing should be bagged and acknowledged the BiPAP orders were added after the observations.
Dialysis Communication and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that one of two residents reviewed, R9, received dialysis care and services in accordance with professional standards of practice, including ongoing communication and collaboration with the dialysis facility. R9 had physician orders dated 1/12/2026 for a right upper extremity AV fistula with instructions not to use the access arm for blood samples, blood pressure, IV fluids, or injections, and an order for dialysis appointments on Monday, Wednesday, and Friday. During interviews, R9 stated she attended dialysis three times weekly and did not voice concerns about her dialysis care or transportation. The facility was unable to provide a dialysis policy, and the EMR contained no communication documents showing information exchange with the dialysis center. The record also showed multiple instances of missing or incomplete documentation related to communication between the facility and the dialysis center. Staff interviews reflected uncertainty about the process for sending residents to dialysis and whether communication was documented in the medical record. The DNS stated that R9 was expected to have a dialysis communication book accompanying her to and from the dialysis center, but confirmed there was no documentation in the medical record reflecting daily communication with the dialysis center. The DNS also confirmed there were no dialysis orders in the EMR and that the admission skin assessment did not indicate R9 had a shunt or was a dialysis resident.
Failure to Timely Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to facility administration and/or to the State Survey Agency (SSA) within the required two-hour timeframe for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, allegations of being hurt by staff resulting in bruising and wounds were reported to the Social Service Worker (SSW) on two occasions. The SSW reported these allegations to the Administrator and Social Service Director (SSD), but there was no evidence that the facility reported or investigated the incidents as required. The Director of Nursing (DON) and SSD acknowledged awareness of the allegations but did not report or document them, with the DON attributing one bruise to a prior fall and the Administrator expressing personal doubts about the validity of the reports, which led to no investigation or reporting. For the second resident, who had heart failure, kidney failure, depression, hypertension, muscle weakness, and was also on hospice care, complaints of rough treatment by staff were made to both the resident's family and facility staff. A Certified Nurse Aide (CNA) reported to the SSD that the resident alleged a staff member had held her hand too hard and caused pain. The SSD documented the allegation in a daily planner but did not report or investigate the incident, and could not recall the reporting CNA. The Administrator later confirmed a lack of awareness and concern that these issues were not reported or investigated as required. These failures were in direct violation of the facility's policy, which mandates immediate reporting of all alleged violations.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to identify and/or investigate allegations of staff-to-resident abuse for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, there were two separate reports made by a hospice social worker that the resident claimed to have been hurt by staff, resulting in bruising and wounds. These reports were communicated to both the facility Administrator and Social Service Director, but there was no evidence that any investigation was initiated or documented by the facility. The Director of Nursing confirmed that no investigation was conducted, and the Administrator could not locate any report of the allegations, acknowledging that they should have been investigated. For the second resident, who was cognitively intact and had multiple medical conditions, a family friend reported bruising, which was subsequently reported to the Administrator. While an incident report was created and some staff interviews were conducted, there was no documentation that the resident was interviewed, that other residents were questioned, or that the cause of the bruising was analyzed. Additionally, there was no evidence of staff training on reporting or investigating injuries of unknown origin, nor documentation of measures to protect the resident or prevent recurrence. The Administrator admitted to being unaware that the investigation was incomplete and agreed that all such allegations should be thoroughly investigated.
Failure to Accurately Code Significant Weight Loss in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect significant weight loss for two residents. For one resident with dysphagia, weight records showed a loss of 8.73% over a short period, but the quarterly MDS assessment did not document this significant weight loss. The resident's care plan noted a risk for weight loss but did not address the actual significant loss that had occurred. During observation, the resident expressed concerns about being skinny, further indicating awareness of her weight change. For another resident with Parkinson's disease and other brain disorders, weight records indicated a 13.54% loss in one month, but the quarterly MDS assessment failed to code this significant weight loss. Progress notes showed interventions such as appetite stimulation and dietician involvement, and the care plan was revised to note significant weight loss at a later date. Staff interviews confirmed that the MDS assessments for both residents did not reflect the significant weight loss, and the DON acknowledged that the MDS should have included this information.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that two of its Certified Nursing Assistants (CNAs) completed the minimum required in-service training hours during the review period from February 1, 2023, to January 31, 2024. Specifically, CNA AA, who worked part-time, completed only 5.5 hours out of the required 6 hours, and CNA FF, who worked full-time, completed only 1.15 hours out of the required 12 hours. This deficiency was identified during a staff development review conducted on July 5, 2024, as documented in the Alliant Certified Nursing Assistant (CNA) Annual Report. The facility's policy mandates that each nurse aide must receive at least 12 hours of in-service training annually, based on their employment date. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of in-service training hours. The Assistant Director of Nursing (ADON) stated that management was collectively responsible for overseeing in-services and education, but there was no designated person for this task. The ADON was unaware of the non-compliance of CNAs AA and FF with their in-service hours. Similarly, CNA AA was not aware of her shortfall in meeting the in-service education requirement, although she believed she had completed the necessary training. The Director of Nursing expressed an expectation that all CNAs should have their in-service hours completed to prevent potential negative outcomes affecting resident safety.
Failure to Document and Communicate Resolutions to Resident Concerns
Penalty
Summary
The facility failed to ensure proper follow-up and communication regarding resident concerns and recommendations voiced during Resident Council meetings. The review of the facility's policy on Resident Council Meetings indicated that the Activity Director was responsible for facilitating meetings and responding to written requests from the group. However, the facility did not document responses to concerns or recommendations, nor did they provide evidence of thorough investigation or resolution of these issues. This lack of documentation and follow-up was evident in the review of nine Resident Council meeting minutes, which were incomplete and lacked evidence of resolution or satisfaction from the residents. During a Resident Council Meeting, several residents expressed that they had voiced concerns and recommendations but had not received any follow-up or resolutions. Additionally, these residents were unaware of how to file a grievance or who the grievance official was. Interviews with the Activity Director and the Director of Nursing revealed that while concerns were verbally communicated to residents, there was no documentation of resolutions. The Director of Nursing acknowledged the need for documentation and expressed that staff were expected to document resolutions to residents' concerns.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the disrepair of furniture and packaged terminal air conditioners (PTACs) in six out of 56 resident rooms. Specifically, rooms A6-2, B10-1, and C18-2 had dressers with missing drawers and/or knobs, while rooms C13, C15, C18, and C19 had PTACs that leaked water onto the floors. These deficiencies were identified through observations, resident and staff interviews, and a review of the facility's maintenance policy. The policy required routine inspections and immediate correction of any issues, which were not adhered to in this case. During an interview, the Maintenance Director confirmed the observations and acknowledged that the PTACs had been leaking intermittently over the past month due to extreme heat causing increased condensation. Despite the units still functioning, they were not effectively directing the fluid outside, leading to water accumulation on the floors. The Maintenance Director, who worked alone, stated that he cleaned the affected floors every two to three days but had no immediate plans to replace the PTACs. He also mentioned difficulties in conducting routine rounds due to his workload, which contributed to the ongoing issues with the facility's environment.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices, which are crucial for preventing infections and cross-contamination. During an observation on Hall A, Certified Nursing Assistants (CNAs) were seen distributing lunch trays to residents without using hand sanitizer between each delivery. Despite being reminded by a Registered Nurse (RN) to use hand sanitizer, the CNAs continued to neglect this practice. This oversight was observed in multiple rooms, indicating a pattern of non-compliance with the facility's hand hygiene policy. Interviews with the CNAs revealed that they were aware of the requirement to use hand sanitizer but admitted to forgetting to do so. Both CNAs also disclosed that they had not received any handwashing hygiene training since starting their employment at the facility, although they had learned about it during their initial CNA training. The Director of Nursing confirmed that the expectation was for all CNAs to adhere to proper hand hygiene protocols to prevent infection control issues and ensure resident safety.
Failure to Document Change of Condition and Transfer
Penalty
Summary
The facility failed to ensure accurate and timely documentation of a resident's change of condition, as required by its own policy and professional standards. A resident with multiple complex diagnoses, including hypertensive heart and chronic kidney disease, end stage renal disease, dementia, and dependence on dialysis, experienced a significant change in condition characterized by altered mental status, fever, and respiratory distress. The resident was ultimately sent to the emergency department, where diagnoses included hypernatremia, dehydration, acute respiratory failure, sepsis, and pneumonia. Despite these events, there was no documentation in the resident's medical record, nurses' notes, 24-hour report, or SBAR report regarding the change of condition or the events leading to the transfer. Staff interviews confirmed that the nurse and nurse practitioner assessed the resident and arranged for transfer to the hospital, but failed to document the assessment, observations, or rationale for the transfer at the time of the event. The nurse practitioner only wrote an order to send the resident out, without specifying the reason, and the LPN believed she had charted the information but had not. The CNA reported changes in the resident's behavior and communicated this to the nurse, who then took action, but again, no documentation was made at the time. The lack of documentation was only discovered after surveyor inquiry, at which point late entries were made.
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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 Flowery Branch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Lanier | 6.3 mi | ★★★★★ | 0 | 0 |
| New Horizons Limestone | 11 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Limestone | 11.2 mi | ★★★★★ | 0 | 0 |
| Bell Minor Home, The | 11.4 mi | ★★★★★ | 1 | 0 |
| Willowbrooke Court At Lanier Village Estates | 13.1 mi | ★★★★★ | 3 | 0 |
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