Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Fairburn Heights Of Journey Llc during CMS and state inspections, most recent first.
Improper Food Storage in Walk-In Freezer: Surveyors found multiple food items in the walk-in freezer that were not properly labeled, dated, sealed, or stored per policy, including an opened freezer-burned bag of eggs, an expired pimento cheese spread container, unopened bags of dry noodles with unclear dates, and several expired or rotted produce items. The CDM confirmed the findings and stated dietary staff were expected to routinely inventory the freezer and document received, open, and expiration dates.
Surveyors observed heavy dust accumulation on PTAC filters in multiple resident rooms, along with debris on one PTAC unit, a rusted toilet tissue dispenser, and multiple nails protruding from a wall. The ADM and Maintenance Director confirmed the conditions and acknowledged that all PTAC units on the unit were in the same condition.
A resident admitted with multiple diagnoses, including septic knee infection and pressure ulcers, had IV antibiotic orders and a PICC line placement order, but the admission MDS documented a midline catheter instead of the ordered PICC. The resident arrived without IV access, the on-call MD was notified, and an IV company later inserted the line, while the MDS coordinator said she assumed the resident had a midline because the prior company only placed midlines. During observation, the resident had IV access with an undated dressing, and the DON stated assessments and PICC or midline dressings were expected to be accurate and dated.
A resident with paraplegia, cognitive communication deficit, schizophrenia, bipolar disorder, and major depressive disorder was not properly tracked for PASRR level II review. The facility’s PASRR records did not include the resident on the level II list, and staff interviews confirmed the resident had been overlooked despite the diagnoses and an active care plan addressing mood instability, depression, mania, and risk for harm to self or others.
Failure to Follow Fall Mat Intervention in Care Plan: A resident with a fall risk care plan, Hospice status, and multiple physician orders was repeatedly observed in bed without the planned fall mat on either side of the bed. Staff interviews confirmed the mat was not in place, and an RN supervisor reported finding the resident on the floor beside the bed after a fall with no fall mat present.
Failure to Document Routine Suprapubic Catheter Changes: A resident with a suprapubic catheter and diagnoses including obstructive/reflux uropathy and BPH had a physician order for monthly catheter changes, but EMR review found no documentation verifying the catheter was changed during the ordered interval. The resident was observed alert and responsive with the catheter draining to a bedside bag, and LPNs and the ADON confirmed the missing documentation.
Oxygen equipment was not properly maintained or secured for a resident with respiratory failure, COPD, and shortness of breath. The resident was ordered oxygen at night via nasal cannula, but surveyors observed an O2 concentrator that was continuously beeping, covered in dirt, and had a heavily soiled filter with dust and debris; the service tag was expired by five years. An unsecured O2 tank was also found standing upright and unsupervised in the resident’s room. The resident said the beeping had been happening for months and she had complained to the DON, while the DON and ADON were unaware of the issues.
Failure to provide required RN coverage: Staffing records showed zero RN hours on multiple days, and the facility could not verify that an RN was physically present for at least 8 consecutive hours. The DON and Administrator confirmed that all RNs were salaried, did not clock in or out, and that documentation was unavailable to prove RN presence, despite the expectation for daily RN coverage and weekend coverage by the DON, ADON, or supervisor.
Staff failed to follow hand hygiene and EBP procedures during resident care. Two residents with wounds and IV access were care planned for EBP, but their room had no EBP signage, no PPE supplies, and no trash can for PPE disposal, and staff provided care while wearing gloves only. During wound care for a resident with a PICC line and wound care needs, an LPN changed gloves without performing hand hygiene between glove changes, and a CNA was also observed delivering a tray without hand hygiene on entry or exit.
The facility did not ensure menus were prepared in advance with required details such as serving sizes and diet-specific modifications. After a kitchen fire, staff relied on emergency menus but failed to provide clear documentation or guidance for dietary modifications and portion sizes. Residents received meals that did not match planned menus, and dietary staff lacked instructions for preparing meals according to individual diet orders, placing all residents at risk of nutritional issues and dissatisfaction.
The facility did not maintain required infection control surveillance documentation for the previous year, as confirmed by the DON. A resident was treated for a UTI during this period, but no surveillance records were available to track or monitor infections as outlined in the facility's policy.
Surveyors observed that multiple resident rooms and the main dining room had significant maintenance issues, including damaged drywall, missing or broken tiles, worn furniture, and broken window blinds. Facility staff confirmed awareness of some of these problems, and incomplete repairs were noted during the inspection.
The facility failed to maintain proper food safety and sanitation practices, with unlabeled and expired food items found in storage, and a lack of temperature logs for kitchen equipment. The kitchen environment was unsanitary, with appliances and preparation areas covered in grime. Staff interviews revealed a lack of awareness and adherence to food safety protocols.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate. Three residents received incorrect dosages of medications, as confirmed by an LPN. The DON expects staff to follow physician orders and monitors compliance through audits and observations.
The facility failed to provide meals that were palatable, appetizing, and attractive, affecting 97 residents. Observations showed meals deviated from the planned menu, such as serving a meatless hotdog bun with cheese and chicken noodle soup. The Dietary Manager cited ingredient shortages as the reason for substitutions, while the Registered Dietitian noted that alternate menu choices should be available but had not verified their posting.
The facility failed to properly label and store bath basins, bedpans, and urinals in several rooms, as required by their infection control policy. Observations showed these items were not bagged or labeled, which was confirmed by staff interviews, including a CNA, an LPN, and the DON. This deficiency highlights a lapse in maintaining a sanitary environment to prevent cross-contamination.
The facility failed to assess the ability of four residents to self-administer medications, resulting in medications being left at their bedside without proper authorization. Despite the facility's policy requiring secure storage of medications, observations revealed that medications were left at the bedside for residents with various diagnoses, including lupus, Alzheimer's, and diabetes, without documented assessments for self-administration. The DON confirmed that no residents had self-administration orders, and all medications should be administered under supervision.
The facility failed to honor residents' meal preferences and provide snacks, affecting 108 residents. Residents reported not receiving snacks, cold food, and lack of assistance to the dining room. The Dietary Manager admitted to substituting meals due to menu changes, and the Registered Dietitian noted gaps in providing alternatives and missing menu cards on trays, crucial for dietary communication.
A facility failed to provide a resident and their representative with written bed hold information at the time of hospital transfer or within 24 hours, as required by policy. Despite multiple hospitalizations, there was no evidence of compliance with this requirement. Interviews with staff confirmed the oversight, and the Administrator was unaware of the lapse.
A facility failed to complete a PASARR Level 2 assessment for a resident with schizophrenia and other medical conditions, who was admitted with only a Level 1 assessment from the hospital. Despite the resident's complex needs and use of psychoactive medications, the necessary Level 2 review was not conducted. Interviews revealed that the hospital did not complete the Level 2 assessment in 2021, and the facility did not initiate it upon admission.
A resident with multiple diagnoses was discharged without proper medication reconciliation and documentation. The discharge summary lacked a complete list of medications and necessary signatures, and there was a discrepancy in the resident's code status. Interviews revealed that the resident did not receive all medications, and specific information about their functional level was missing. The LPN admitted to not making a copy of the medication form for the medical record.
The facility failed to ensure a safe environment for three residents, who were found with hazardous items like nail polish remover, isopropyl alcohol, and Hibiclens Antiseptic in their rooms. Despite efforts to declutter and inform residents about prohibited items, these hazards were present. The DON acknowledged the issue of clutter and inappropriate items in resident rooms.
The facility failed to provide effective oxygen therapy for four residents, with issues such as improper storage of equipment, lack of physician orders, and inadequate documentation. One resident with a tracheostomy had essential equipment on the floor, while another received oxygen without an order. Two other residents experienced inconsistencies in oxygen flow rates and documentation, indicating systemic issues in respiratory care management.
A facility failed to document communication between its staff and a dialysis center for a resident with end-stage renal disease. The facility's policy requires ongoing assessment and communication, but several dialysis communication forms were incomplete or missing. Interviews with staff, including an LPN and the DON, confirmed the lack of documentation, which was not addressed until highlighted during a survey.
The facility did not provide meals and snacks according to residents' needs and preferences, affecting 97 out of 112 residents. Despite a policy requiring adjustment of menus to meet individual needs, residents reported not receiving snacks at night. The Dietary Manager admitted to limiting snacks due to concerns about food going missing, and an LPN confirmed that snacks were not offered. The Administrator was unaware of the limited snack provision.
Improper Food Storage in Walk-In Freezer
Penalty
Summary
The facility failed to properly store opened, unopened, and sealed food items in the walk-in freezer in accordance with its policy titled Food Storage: Cold Foods, which requires food items to be stored, wrapped or kept in covered containers, labeled, dated, sealed, and arranged appropriately. During observation, surveyors found an opened freezer-burned bag of eggs that was not securely closed and had no labeled open date or expiration date, as well as an opened expired container of pimento cheese spread with a best-by date of 02/05/2026. The Certified Dietary Manager confirmed these items were present and acknowledged that dietary staff were expected to routinely inventory the walk-in freezer and document received, open, and expiration dates. Additional observations in the walk-in freezer identified two unopened five-pound bags of dry noodles that did not have labeled open dates or expiration dates, with dates of 12/22/2026 and 01/06/2026 written on the bags, and the CDM stated he could not confirm whether those dates were received or expiration dates. Surveyors also found a bag of unopened rotten potatoes with an expiration date of 01/12/2026, an opened expired bag of green onion with an expiration date of 01/30/2026, a bag of unopened rotted green onion with an expiration date of 01/19/2026, and a bag of unopened rotted green celery with an expiration date of 01/16/2026. The CDM confirmed these items were in the freezer and stated he expected dietary staff to date opened food items before storage and to routinely inventory the walk-in freezer to ensure received, opened, and expiration dates were in accordance with regulation and policy.
Dirty PTAC Units and Wall Nails
Penalty
Summary
The facility failed to ensure Packaged Terminal Air Conditioning (PTAC) units were free of dust and debris in five resident rooms, and failed to ensure nails protruding from a wall were removed to prevent accident hazards. During the initial tour, surveyors observed a heavy accumulation of dust on PTAC filters in multiple resident rooms, along with a rusted toilet tissue dispenser in one bathroom and toilet tissue propped on top of the holder because it could not be secured. In one room, debris resembling food crumbs was observed on top of the PTAC unit and on the control panel, and multiple nails were protruding from the wall. Additional observations on a later date again revealed heavy dust accumulation on PTAC filters in resident rooms 210, 211, 212, 213, and 214. The Administrator and Maintenance Director observed the dirty PTAC filters and other general plant matters with surveyors and confirmed the condition of the units. The Maintenance Director stated he would clean all PTAC units on the unit that afternoon, and the Administrator acknowledged that all PTAC units on the unit were in the same condition.
Incorrect IV Access Assessment on Admission
Penalty
Summary
The facility failed to correctly assess and identify intravenous (IV) access ordered and inserted the day after admission for one sampled resident, R127. The facility’s policy titled MDS 3.0 Completion stated that assessments must be accurate and correct, and that the PPS assessment needs to be correct and accurate. R127 was admitted with diagnoses including metabolic encephalopathy, staphylococcal arthritis of the left knee, kidney disease stage 2, chronic embolism, thrombosis of deep veins of the left lower extremity, and a sacral pressure ulcer. The admission MDS documented moderate cognitive impairment, dependence for multiple activities of daily living, incontinence of bowel and bladder, a stage 3 pressure ulcer, and three venous/arterial ulcers present on admission. The record also showed physician orders for IV antibiotic therapy, including vancomycin and ceftriaxone sodium solution, along with a PICC line placement order and PICC line care. The admission progress note stated the resident arrived without IV access, the on-call physician was notified, and orders were received for PICC line placement. The note further stated that the IV company was called and would place the line in the morning. However, the admission MDS later documented IV access as a midline catheter for antibiotic therapy. During observation on 02/10/2026, the resident had IV access with a gauze under a clear dressing and no date on the dressing. In interview, the resident was confused about the situation and stated she thought the dressing had been changed the day before. The MDS coordinator stated the resident came in with no IV access, that the floor nurse called pharmacy to have the IV access team insert access, and that she assumed the resident had a midline because the prior company only placed midline access. She also confirmed the physician’s PICC line order and later produced documentation showing PICC line insertion. The DON stated her expectation was that admission assessments be correct and accurate and that PICC and midline dressings be dated at the time of change.
Failure to Complete PASRR Level II Review for Resident With Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that one of 46 sampled residents, R7, was assessed for PASRR level II and referred to the appropriate state-designated authority for evaluation and determination of specialized services when warranted. The facility policy stated that it coordinates assessments with the PASRR program and that the Social Services Director is responsible for tracking each resident’s PASRR screening status and referring to the appropriate authority. Review of R7’s EMR showed diagnoses including paraplegia, cognitive communication deficit, schizophrenia, bipolar disorder, and major depressive disorder, and the quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. Review of the PASRR records showed R7 was not listed on the PASRR level two list, while a PASRR level one dated 06/05/2026 was approved and a PASRR level two dated 02/12/2026 was pending. The resident’s care plan addressed mood problems related to bipolar disorder, major depressive disorder, and schizophrenia, with interventions for monitoring signs and symptoms of depression, mania, hypomania, suicidal behavior, and risk for harm to self or others. During interviews, the ADON stated she was not responsible for the PASRR process, the Administrator confirmed R7 had been overlooked and should have been included because of her diagnoses, and the Social Service Director stated she processed PASRRs but could not locate a submission for R7 after auditing residents with schizophrenia, depression, and bipolar disorder.
Failure to Follow Fall Mat Intervention in Care Plan
Penalty
Summary
The facility failed to follow the interventions of the comprehensive care plan for R12, whose care plan dated 02/07/2026 identified a problem of risk for falls. The plan included an intervention for a fall mat on the floor on the right side of the bed when the resident was in bed. R12 was also noted to be with Hospice and Full Code, and had a condition or chronic disease that may result in a life expectancy of less than six months. Physician orders included wound care to a sacral wound, EBP, tramadol 50 mg four times daily, lorazepam 1 mg every 4 hours as needed, morphine 20 mg/ml 0.25 ml every 2 hours for severe pain, a scopolamine transdermal patch 1 mg changed every 3 days, and carbidopa-levodopa 10-100 mg four times a day. Observations on 02/10/2026, 02/11/2026, and 02/12/2026 showed R12 in bed with half side rails in place and the bed in the lowest position, but no fall mat was present on either side of the bed as care planned. On 02/12/2026, R12 was observed lying in bed with the head of bed elevated 45 degrees and leaning to the right, with no fall mats on the floor. An LPN stated she did not recall a fall mat beside R12's bed. An RN supervisor stated she found R12 sitting on the floor beside the right side of the bed after being told by a CNA that the resident had fallen, and no fall mat was present. The DON confirmed there were no fall mats in place on R12's floor, and the Administrator stated he expected whatever the policy stated to be done.
Failure to Document Routine Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure physician orders were followed and documented for routine suprapubic catheter changes for one resident with diagnoses including obstructive and reflux uropathy, benign prostate hyperplasia with lower urinary tract symptoms, and a personal history of malignant neoplasm of the prostate. The physician order dated 11/10/2025 directed that the resident's suprapubic catheter, a 20 French catheter with a 10 mL balloon, be changed monthly and as needed. Review of the EMR and care plan identified catheter-related interventions on 10/14/2025, when the catheter was dislodged and replaced, and on 01/08/2026, when a catheter change and irrigation were documented. However, no documentation was found showing that the suprapubic catheter was changed between 10/24/2025 and 01/08/2026. During observation on 02/11/2026, the resident was alert and responsive with the suprapubic catheter in place draining to a bedside collection bag. LPNs GG and HH stated they could not locate documentation verifying a catheter change during that period, and the ADON confirmed there was no documented evidence of a catheter change during that timeframe.
Oxygen Equipment Not Properly Maintained or Secured
Penalty
Summary
Proper respiratory care was not provided for one resident receiving oxygen therapy. R58 had diagnoses including acute and chronic respiratory failure with hypoxia, COPD with acute exacerbation, and shortness of breath. Physician orders directed oxygen at night during sleep via nasal cannula, first at 2 L/min and later at 4 L/min. During observations, R58 was receiving oxygen through an O2 concentrator that was continuously beeping, and the concentrator was observed to be covered in dirt with a heavily soiled filter containing visible dust and debris. The service tag on the concentrator was expired by five years. An unsecured oxygen tank was also observed standing upright and unsupervised in R58's room while not in use. R58 stated the loud beeping from the concentrator had been occurring for months and that she had complained to the DON, but no one responded to her concerns. The DON stated she was not aware of any issues with the concentrator or the unsecured oxygen tank and said the ADON was responsible for monitoring oxygen concentrators and respiratory equipment. The ADON stated the concentrators were cleaned routinely and that the Unit Managers were responsible for them, but she was not aware of any issue with R58's concentrator.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week on six identified days. Based on record review, staff interviews, and review of the facility’s Emergency Staffing policy, staffing records showed zero RN hours on 04/06/2025, 05/03/2025, 05/24/2025, 05/25/2025, and 05/26/2025, and the facility could not provide documentation to verify that an RN was physically present for the required coverage. Payroll reflected salaried RN coverage on those dates, but no supporting evidence was available to confirm presence in the building. The DON stated that all RNs were salaried and did not clock in or out, and explained that the facility’s process was for an RN to be present Monday through Friday, with the DON or ADON covering when needed and weekend coverage provided by the supervisor or one of them. The Administrator also confirmed that the facility could not provide evidence of RN presence on the identified dates and acknowledged that documentation was not available to verify coverage. The census was 110, and the report stated the failure had the potential to affect all residents residing in the facility.
Hand Hygiene and EBP Failures During Resident Care
Penalty
Summary
The facility failed to provide an infection prevention and control program when staff did not use proper hand hygiene during wound care for one resident and did not provide signage or PPE protocols for two residents who were care planned for enhanced barrier precautions (EBP). The report states that the facility’s policy required hand hygiene before donning gloves and immediately after removing gloves, and that EBP residents with wounds or indwelling medical devices were to have gowns and gloves available near the room, alcohol-based hand rub access, and a trash can for PPE disposal. Resident R127 was admitted with diagnoses including metabolic encephalopathy, staphylococcal arthritis of the left knee, atherosclerosis with intermittent claudication, kidney disease stage 2, and chronic embolism and thrombosis of the left lower extremity. Her MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and she required extensive assistance with activities of daily living. Her care plan included IV antibiotic therapy for a septic left knee and EBP related to wounds and midline IV access, and the hospital record showed an order for a PICC line for IV antibiotic therapy. During observation, R127 had a vascular access PICC line with no date on the dressing, and she and another resident in the room, R88, were observed without EBP signage outside the room, without PPE available, and without a trash can for PPE removal. Multiple observations showed staff entering the room and providing care without the required EBP setup. LPNs and CNAs repositioned and provided personal care to R127 and R88 while wearing gloves but no gowns, and a CNA delivered a breakfast tray without hand hygiene on entry or exit. R88 was observed on a low air mattress with a wound on her bottom, and there was no signage or PPE available for either resident. During wound care for R127, the wound care LPN performed hand hygiene and donned PPE at the start, but then removed dirty gloves and put on clean gloves without hand hygiene between glove changes while completing the dressing change. The LPN later stated she did not use hand sanitizer between glove changes and had been told not to bring hand sanitizer into the room; the DON confirmed she expected wound care to be done in an aseptic manner.
Failure to Prepare and Follow Advance Menus with Diet-Specific Modifications
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and included necessary details such as serving sizes and diet-specific modifications for residents' diet orders. During the survey, the facility was unable to provide complete menu cycles and menu extensions for all diets, and the available documentation did not specify which foods were appropriate for various modified diets, including soft, bite-sized, potassium-restricted, finger food, reduced sodium, no added salt (NAS), and renal diets. Observations revealed that meals served did not always match the planned emergency menus, and handwritten instructions for meal preparation lacked information on portion sizes and diet accommodations. Staff interviews confirmed that, following a kitchen fire, the facility relied on emergency menus but did not consistently provide documentation or guidance for dietary modifications or portion sizes. Residents reported receiving meals that differed from the emergency menu, and dietary staff were observed preparing meals without clear instructions on the amount of food to serve or how to modify meals for specific diets. The Registered Dietician stated that the food service vendor provided menus and recipes for all diets, but these were not fully utilized by the dietary manager during the emergency period. The facility was unable to provide a dietary policy regarding menu preparation and documentation before the survey exit, and the lack of clear, advance menu planning and documentation placed all residents receiving oral meals at risk of nutritional problems and dissatisfaction.
Missing Infection Control Surveillance Documentation
Penalty
Summary
The facility failed to maintain infection control surveillance documentation for the year 2024, as required by its own policy. Review of the facility's Infection Surveillance policy indicated the purpose was to identify and monitor infections to reduce and prevent their spread. However, the only available surveillance documentation was for January through June 2025, with no records for 2024. This deficiency was confirmed during an interview with the DON, who was unable to provide any infection control surveillance records for 2024. Additionally, a resident was treated for a urinary tract infection in December 2024, with supporting documentation in the medical record, but there was no corresponding infection surveillance documentation for that period.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as required by its own policy. Observations conducted across four units revealed multiple deficiencies in 13 resident rooms and the main dining room. Specific issues included gouged and marred drywall, missing or broken tiles, dark discoloration around baseboards, worn laminate on tables, splintered wood on doors, and missing or damaged window blinds. Additional findings included holes in bathroom doors, unsanded and unpainted wall patches, separated drywall seams, missing base molding, and missing drawers in closets. Interviews with the Maintenance Director and Regional Maintenance Director confirmed awareness of some of these issues, with the Maintenance Director acknowledging incomplete repairs, such as unsanded and unpainted drywall patches. The Regional Maintenance Director indicated he was new to the corporation and unaware of the extent of the repair needs. These conditions were directly observed and documented by surveyors during their inspection.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, as observed during a kitchen tour. Several food items in the walk-in cooler and freezer were not labeled or dated, including a container of tea, shredded lettuce, cooked sausage patties, and hot dog buns. Additionally, expired food items such as yogurt and relish were found. The facility also lacked records of daily temperature logs for the freezers, cooler, dishwasher, steam table, and sanitizing solution in the three-compartment sink. This lack of monitoring and documentation could potentially affect 97 of the 112 residents receiving an oral diet. The kitchen environment was found to be unsanitary, with appliances such as the oven, fryer, and convection oven coated in grease and grime. Food preparation areas, countertops, and floors were soiled with food crumbs, dirt, and debris. The ice machine contained a black substance, and the sanitizing sink was surrounded by debris and food particles. The facility's maintenance worker confirmed that the ice machine is cleaned every three months, but there were no logs or manufacturer's cleaning recommendations available. Interviews with the Dietary Manager, Administrator, and kitchen staff revealed a lack of awareness and adherence to food safety protocols. The Dietary Manager confirmed the absence of temperature logs and acknowledged the environmental concerns in the kitchen. The day shift cook was unaware of the requirement to log steam table temperatures, and the Dietary Aid mentioned the absence of a cleaning list. The Administrator recognized the need for a deep clean of the kitchen and acknowledged the potential risk of illness from a dirty ice machine.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency was identified through observation, record review, and staff interviews. Three residents were involved in the medication errors. Resident 44, diagnosed with Alzheimer's Disease and urinary retention, was administered Cranberry 450mg instead of the ordered Cranberry 425mg. Similarly, Resident 46, with Type 2 Diabetes Mellitus and a history of cerebral infarction, received Cranberry 450mg instead of the prescribed Cranberry 425mg. Resident 61, who has a history of cerebral infarction and prediabetes, was given Vitamin D3 125mcg instead of the ordered Vitamin D3 25mcg. The errors were confirmed during an interview with an LPN, who acknowledged the discrepancies between the medications given and the physician's orders. The Director of Nursing (DON) expressed an expectation for staff to adhere to physician orders and indicated that her role includes monitoring staff through audits and observations to ensure compliance. Despite these expectations, the facility's failure to ensure accurate medication administration led to a medication error rate exceeding the acceptable threshold.
Deficiency in Meal Quality and Menu Adherence
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, appetizing, and attractive, affecting 97 of 112 residents on an oral diet. The facility's policy required that menus meet nutritional needs, be prepared in advance, and deviations be documented and approved by a dietitian. However, observations revealed that meals served did not adhere to these standards. For instance, a meal consisting of a meatless hotdog bun with a slice of cheese, chicken noodle soup, and a side of lettuce was deemed unacceptable by the Administrator and Regional Nurse Consultant. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) highlighted issues with menu adherence and food availability. The DM admitted to substituting menu items due to a lack of ingredients, such as using a hotdog bun instead of bread and omitting meat from salads due to a shortage of deli meats. The RD confirmed that alternate menu choices should be available and communicated to residents, but acknowledged that she had not verified if these were posted. The facility's menu was on a 30-day cycle, but frequent changes led to inconsistencies in meal offerings.
Failure to Properly Store and Label Personal Care Items
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment by not labeling and properly storing bath basins, bedpans, and urinals in eight of 49 rooms. Observations revealed that in several rooms on the 300 hall, including rooms 309, 313, 315, 402, 404, 405, 407, and 408, bath basins and bedpans were not labeled or bagged as required by the facility's policy. The policy, dated 2/12/2022, mandates that bedpans and urinals are for single resident use only, should be labeled with the resident's name, and stored in a plastic bag in the resident's bedside cabinet or drawer. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, confirmed that all urinals and bath basins should be bagged and labeled to prevent cross-contamination. The CNA stated that all basins and urinals should be cleaned after each use and changed out every night. Despite these guidelines, the observations indicated a failure to comply with the policy, leading to a deficiency in infection prevention and control within the facility.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of four residents to self-administer medications before leaving medications at their bedside, contrary to the facility's policy on medication storage. The policy mandates that all medications should be stored securely and not left at the bedside unless a clinical assessment deems it appropriate for self-administration. However, observations revealed that medications were left at the bedside for residents R56, R44, R41, and R21 without documented assessments for self-administration. Resident R56, diagnosed with lupus erythematosus, asthma, and other conditions, had several medications, including Trelegy Ellipta Inhaler and Zinc Oxide Ointment, left at the bedside. The Director of Nursing (DON) and the Infection Control Nurse confirmed the presence of these medications, which were not supposed to be there. Similarly, Resident R44, with Alzheimer's Disease and other diagnoses, had Triamcinolone cream at the bedside, which was discontinued earlier in the year. The LPN confirmed the presence of the discontinued medication but was unaware of who left it there. Resident R41, who was cognitively intact, had nasal spray and eye drops at the bedside without an order for self-administration. The LPN confirmed that these medications should not have been left at the bedside. Resident R21, with a BIMS score indicating no cognitive impairment, had diclofenac sodium gel at the bedside without an order for self-administration. The DON confirmed that no residents in the facility had self-administration orders, and all medications should be administered under supervision, ensuring residents take their medications before staff leave the room.
Failure to Honor Resident Meal Preferences and Provide Snacks
Penalty
Summary
The facility failed to honor residents' rights to make choices related to meals and snacks, affecting 108 of 112 residents who can consume meals. The facility's policy stated that the residents' council would be included in menu planning, and alternatives would be provided if a food group was missing from a resident's diet. However, a review of the last six months of resident council meeting minutes revealed complaints about not receiving snacks, cold food, and lack of assistance to the dining room. Observations confirmed that no residents were in the dining room for dinner, and interviews with residents indicated that they were not informed about snack availability and that meal preferences were not honored. Interviews with the Dietary Manager and Registered Dietitian highlighted issues with menu management and communication. The Dietary Manager admitted to substituting meals due to constant menu changes and advised not to rely on the distributed menu. The Registered Dietitian acknowledged gaps in providing alternatives and noted the absence of menu cards on trays, which are crucial for communicating dietary preferences and allergies. These deficiencies in meal service and communication contributed to the failure to support resident choice and self-determination regarding meals and snacks.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide written bed hold information to a resident and their representative at the time of transfer to the hospital or within 24 hours, as required by their policy. This deficiency was identified for one resident, R154, out of three sampled residents. The facility's Bed Hold Policy, dated 2/12/22, mandates that written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed be provided at the time of transfer for hospitalization or therapeutic leave. However, a review of the clinical and financial records revealed no evidence that such information was provided to the resident or their responsible party during multiple hospitalizations. Interviews with facility staff, including the Business Office Manager and an LPN, confirmed that the responsibility for providing the bed hold form lies with the business office manager and licensed nursing staff. The Business Office Manager admitted to not having any electronic or hard copy documentation to show that the bed hold information was provided during the hospitalizations. The Administrator was also unaware that the forms were not being given, despite expecting the staff to provide them. This lack of documentation and communication led to the deficiency being cited by the surveyors.
Failure to Complete PASARR Level 2 Assessment
Penalty
Summary
The facility failed to identify and submit a Preadmission Screening/Resident Review (PASARR) Level 2 review for a resident with a primary diagnosis of serious mental illness, developmental disability, or a related condition. The resident, who has schizophrenia and other medical diagnoses such as hemiplegia and generalized anxiety disorder, was admitted to the facility with only a PASARR Level 1 assessment completed by the hospital. Despite the resident's complex medical and psychiatric needs, including the use of multiple psychoactive medications, the necessary Level 2 assessment was not conducted upon admission. Interviews with facility staff, including the Social Service Director and the administrator, revealed that the PASARR Level 2 was not completed by the hospital in 2021, and the facility did not initiate it upon the resident's admission. The Social Service Director acknowledged that the hospital typically initiates both Levels 1 and 2, but if not, the facility should take responsibility. However, the Level 2 assessment was overlooked, and the Social Service Director was unsure why it was not initiated, as the resident was admitted before her tenure.
Deficiency in Medication Reconciliation and Documentation at Discharge
Penalty
Summary
The facility failed to properly reconcile and document the medications for a resident at the time of discharge, leading to a deficiency in the discharge process. The resident, who had diagnoses including vascular dementia, Parkinson's disease, and type 2 diabetes mellitus, was discharged without a complete and accurate discharge summary. The discharge summary did not list the medications, nor did it include the necessary signatures from the staff and the resident or their family, which are required to confirm that the medications were provided. Additionally, there was a discrepancy in the resident's code status, as the discharge summary incorrectly listed the resident as a full code, while the medical record indicated a Do Not Resuscitate (DNR) status. Interviews with the family and staff revealed that the resident did not receive all prescribed medications upon discharge, and there was a lack of specific information regarding the resident's capabilities and functional level. The Social Service Worker acknowledged the mistake in the code status, and the Director of Nursing confirmed that the discharge summary should have included care instructions, functional level, and medication documentation. The LPN involved admitted to not making a copy of the medication form with the necessary signatures for the resident's medical record, leaving the facility without proof that the medications were given to the resident or their family.
Facility Fails to Prevent Accident Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. Resident 41, who has a history of major depressive disorder, hoarding disorder, and uses a wheelchair, was observed with nail polish remover on their bedside table. The Licensed Practical Nurse (LPN) acknowledged the presence of hazardous items and noted that some rooms have clutter, despite efforts to declutter and inform residents about prohibited items. Resident 9, who is alert and oriented with a history of heart failure and chronic kidney disease, was found with a bottle of isopropyl alcohol on their bedside table. The resident stated they purchased it themselves, and the LPN confirmed its presence, noting that residents and families are informed about restricted items. Resident 24, with hemiplegia and paranoid schizophrenia, had four bottles of Hibiclens Antiseptic on their bedside table. The resident received the bottles from another resident and was educated by a Certified Nursing Assistant (CNA) about not keeping certain chemicals. The Director of Nursing (DON) confirmed awareness of clutter and inappropriate items in residents' rooms.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide effective oxygen therapy for four residents, as observed through various deficiencies in the administration and management of respiratory care. For one resident with a tracheostomy and chronic respiratory failure, essential equipment such as an Ambu bag and suction device were found on the floor, and respiratory tubing was improperly stored, indicating a lack of adherence to infection control measures. This resident's care plan included specific orders for tracheostomy care and oxygen therapy, yet the observed conditions did not align with these requirements. Another resident, who was dependent on supplemental oxygen due to chronic respiratory failure and other conditions, was observed receiving oxygen therapy without a physician's order. Despite being on hospice care and having a care plan that highlighted the need for oxygen, the resident's oxygen therapy was not documented in the Medication Administration Record (MAR), and staff interviews confirmed the absence of an official order. This lack of documentation and oversight suggests a failure in maintaining proper records and ensuring physician-directed care. For two additional residents, discrepancies were noted in the administration of oxygen therapy. One resident had a PRN order for oxygen, but observations revealed inconsistencies in the oxygen flow rate and improper storage of equipment, such as dirty filters and unbagged tubing. Another resident was receiving continuous oxygen therapy without a physician's order or documentation in the MAR, and the care plan lacked any mention of oxygen therapy. Interviews with nursing staff and the Director of Nursing confirmed these oversights, highlighting a systemic issue in the facility's management of respiratory care.
Failure to Document Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication and documentation between its staff and the dialysis center for a resident receiving dialysis. The facility's policy on hemodialysis requires ongoing assessment and communication with the dialysis center, including monitoring the resident's condition before, during, and after dialysis treatments. However, the review of the resident's medical records revealed missing dialysis communication forms for several dates, indicating a lack of documentation of vital signs, assessment of the dialysis access site, and other necessary information. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the forms were incomplete and not properly uploaded into the electronic medical records system. The resident in question had a history of hypertensive chronic kidney disease, end-stage renal disease, legal blindness, and cerebellar stroke syndrome. Despite physician orders for dialysis on specific days, the facility failed to document the necessary information on the dialysis communication forms. The DON acknowledged that the forms were not being completed as required by policy and was unaware of the issue until it was highlighted during the survey. The lack of documentation and communication could potentially impact the resident's care and treatment, as the facility did not ensure that the necessary information was communicated to and from the dialysis center.
Failure to Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were served according to the residents' needs, preferences, and requests, as required by their policy. The policy, dated April 2024, stated that menus and available snacks should be adjusted to meet individual caloric and nutrient-intake needs. However, during a Resident Council meeting, residents expressed concerns about not receiving snacks at night. Observations revealed that the pantry contained only a limited selection of snacks, such as chocolate sandwich cookies, graham crackers, and chocolate wafer bars. The Dietary Manager admitted to providing only a limited number of snacks due to concerns about food going missing at night and confirmed the lack of ingredients to prepare sandwiches. Interviews with staff further highlighted the deficiency. The Administrator was aware of the issue of food going missing but was unaware of the limited snack provision. An LPN stated that snacks were not offered to residents, and only some received a snack bag. This deficiency affected 97 out of 112 residents, as they were not provided with nourishing alternative snacks at non-traditional times or outside of scheduled mealtimes, contrary to the facility's policy and the residents' expressed needs.
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What surveyors actually found near you
We read the 275 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Fairburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian City Rehabilitation Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Fairburn | 5.8 mi | ★★★★★ | 0 | 0 |
| Fountainview Ctr For Alzheimer | 9.4 mi | ★★★★★ | 3 | 3 |
| Healthcare At College Park, Llc | 9.9 mi | ★★★★★ | 0 | 0 |
| Fayetteville Center For Nursing & Healing Llc | 10.1 mi | ★★★★★ | 7 | 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.