Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Fort Valley Crossing Of Journey Llc during CMS and state inspections, most recent first.
A facility failed to follow puree recipes for meals served to residents receiving pureed diets. Staff used a yellow scoop that was too small for pureed mashed potatoes, meat, and mixed vegetables, resulting in portions that were smaller than the recipe specifications, and a Cook/Dietary Aide added water to pureed cinnamon rolls instead of following the recipe calling for milk and commercial thickener with chilling to 41 degrees F or below. The RD and CDM confirmed the portion sizes and preparation did not match the recipes.
Expired and undated food items were found throughout the kitchen, including dry storage, the walk-in cooler, and freezers, with the CDM confirming the findings. Surveyors also observed improper use of the 3-compartment sink when a puree blender bowl was not fully submerged in the sanitation sink, along with spider webs, stained ceiling tiles, dust and bugs in window seals, and debris on the floor; the daily cleaning log showed no kitchen cleaning entries since 12/12/2025.
Unsafe and Disrepair Conditions in Resident Rooms and Bathrooms: The facility failed to maintain a safe, clean, comfortable, homelike environment in multiple resident rooms and shared bathrooms. Surveyors observed missing paint, damaged cove base and baseboards, a hole in a wall, a short overbed light string, and a privacy curtain that did not fully close around a bed. The ADM and Maintenance Dir confirmed the findings and stated the issues were not in the electronic work order system or reported.
A resident admitted with traumatic subarachnoid hemorrhage with loss of consciousness did not have a baseline care plan completed within 48 hours of admission. The clinical record contained no baseline care plan, and the MDS Coordinator stated it was not completed because the resident was a respite resident, while also acknowledging that all residents should have a baseline care plan upon entry. The DON stated she did not initiate one and expected all new residents to have a baseline care plan.
The facility failed to follow a resident’s oxygen therapy care plan when the resident with COPD received O2 at rates above the ordered 2 LPM via NC. The facility also failed to create active care plan interventions for two residents receiving psychotropic meds, including an antidepressant for weight loss and an antipsychotic for schizophrenia, and the DON and MDS Coordinator confirmed the care plans were missing.
The facility failed to provide safe respiratory care when one resident with COPD received O2 at a higher flow rate than ordered and from an oxygen concentrator covered with dust and debris. The facility also failed to verify a physician order before giving O2 to another resident with COPD and respiratory failure, who was observed receiving O2 by NC despite no O2 order being present. The DON confirmed the incorrect flow rate and the absence of an O2 order.
Failure to Follow TBP and Hand Hygiene Practices: A CNA entered a TBP room without PPE and left without hand hygiene, and a housekeeper also entered the room without PPE while sweeping and moving in and out of the room. The CNA said she thought PPE was only needed when doing care for the resident, while the housekeeper said she forgot to put PPE on. The ICP, ADON, and DON stated staff were expected to follow the TBP signage, wear PPE before entering the room, and perform hand hygiene when entering and exiting resident rooms.
The facility failed to follow puree diet recipes, risking residents' nutritional intake. Observations showed unmeasured portions of beef and broccoli were blended without following the recipe, and the Dietary Manager lacked knowledge of portion sizes. Interviews revealed staff were unaware of scoop sizes and nutritional content, highlighting a training gap.
The facility failed to obtain a concurring physician's signature for POLST documents for two residents. One resident, with severe cognitive impairment, signed a DNR POLST without the required concurring physician's signature. Another resident's POLST was signed by a family member claiming to be the POA, but no documentation supported this, and the form also lacked a concurring physician's signature. Staff interviews revealed a lack of understanding of the proper procedures for completing POLST documents.
A resident diagnosed with schizophrenia did not receive a PASARR Level II assessment as required by facility policy. The Social Service Director, responsible for PASARR submissions, confirmed the oversight. Interviews with the Administrator and DON revealed that the expected procedure for handling new qualifying diagnoses was not followed.
A resident received oxygen therapy without a physician's order, and the oxygen concentrator was found to be dirty, contrary to facility policies. The resident, with a history of COPD and other conditions, continued to receive oxygen after returning from a hospital stay without updated orders. Interviews with the ADON and DON confirmed the oversight in obtaining orders and maintaining equipment cleanliness.
A facility failed to follow infection control practices during the administration of ophthalmic drops to a resident. An LPN did not sanitize the bedside table or use gloves as required by the facility's policy. After administering the drops, the LPN did not wash or sanitize her hands before continuing with the medication pass. The DON confirmed that the correct procedure involves handwashing and wearing gloves to prevent cross-contamination.
Puree Recipes Not Followed for Resident Meals
Penalty
Summary
The facility failed to ensure puree recipes were followed for residents receiving pureed meals, affecting 10 of 10 residents who received a puree meal. Review of the lunch menu for 12/20/2025 showed country-fried steak with onion gravy, roasted potatoes, California medley vegetables, dinner roll, brownie crinkle cookie, margarine, and a beverage of choice. The pureed food recipes for that meal specified scoop #8.2 for pureed country-fried steak, scoop #20 for pureed California medley, and scoop #10 for mashed potatoes. During observation in the kitchen, the Assistant Dietary Manager served pureed mashed potatoes, pureed meat, and pureed mixed vegetables using a yellow-handled scoop that measured 1.58 oz. The Regional Dietitian stated the yellow scoop was too small and confirmed the portion sizes on the pureed trays were too small, adding that dietary staff should follow the recipes to determine portion sizes. Review of the breakfast menu for 12/21/2025 showed orange juice, hot oatmeal, scrambled eggs, bacon, cinnamon roll, coffee, and milk. During observation of pureeing cinnamon rolls, Cook/Dietary Aide BB added 3 tablespoons of water to the blender to thin the puree, even though the recipe called for milk and commercial thickener and instructed that the mixture be chilled to 41 degrees F or below and held at that temperature for service. The CDM confirmed water should not have been used and that the recipe should have been followed.
Expired and Undated Food Items with Unsanitary Kitchen Conditions
Penalty
Summary
Food items in the kitchen were found to be improperly labeled, dated, and stored, and several items were expired or beyond their use-by dates. During the initial kitchen tour with the Certified Dietary Manager (CDM), surveyors observed a can of pineapples on the floor, a bag of stone ground yellow grits on the floor with a 12/17/2024 date, an opened bag of brownie mix with a use-by date of 11/21/2025, a box of dressing with a use-by date of 12/13/2025, and three cans of chicken with a use-by date of 11/19/2025. In the walk-in cooler, surveyors observed a green bell pepper with a gray substance on it, an open bag of cole slaw without an open date or use-by date, and an undated box of whipped topping. In the freezers, there were bags of pastries and pies without open dates or use-by dates, and boxes of turkey sausage, bologna, and chicken with received dates but no use-by dates. A large clear storage container with cereal also lacked an open date or use-by date. The CDM confirmed the expired and undated items found during the tour. Surveyors also observed improper use of the three-compartment sink and unsanitary kitchen conditions. A puree blender bowl was not fully submerged in the sanitation sink and remained there until removed later. During a later kitchen visit, surveyors observed spider webs, stained ceiling tiles, dust and bugs in the window seals, and the CDM stated he was unsure about cleaning the window seals. The CDM stated that cooks should check for expired items and ensure everything was labeled, and that he goes behind them to make sure these tasks are done. Although the CDM stated the kitchen staff sweep and mop the dry storage area daily, buildup on the floors, straws, and other items remained on the floor, and the daily cleaning log showed no entries indicating the kitchen had been cleaned since 12/12/2025.
Unsafe and Disrepair Conditions in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, homelike environment for nine of 28 rooms, including Rooms 202, 204, 206, 208, 210, 302, 303, 304, and 306. Observations on 12/19/2025 identified multiple environmental issues, including missing paint and disrepair of cove base in shared bathrooms, a hole in the wall near a bathroom door, missing paint behind the headboards in a room with A and B beds, a short overbed light string, a privacy curtain that did not pull completely around the bed, and missing baseboards around sinks and behind toilets. These conditions were observed in both resident rooms and shared bathrooms. During rounding and interviews on 12/21/2025, the Administrator and Maintenance Director confirmed the concerns, including the missing cove base by a sink, the hole in the wall, the short overbed light string, missing paint at the head of the bed, a loose baseboard behind a toilet, and cove base in disrepair in multiple rooms and bathrooms. The Maintenance Director stated he was unaware of the identified issues, said he conducted environmental rounds daily, and confirmed that none of the identified areas were in the electronic maintenance work order system or had been reported. The Administrator stated his expectation was for staff to complete a work order in the electronic system and notify the Maintenance Director so he could follow up based on the order and urgency.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan for R55 within 48 hours of admission. R55 was admitted with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, and the clinical record contained no baseline care plan. The facility policy titled Baseline Care Plan stated that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. During interviews, the MDS Coordinator stated that because R55 was a respite resident, a baseline care plan was not completed, but also stated that a baseline care plan should be completed for all residents upon entry to the facility. The DON stated that she did not initiate a baseline care plan for R55 and that it was her expectation for all new residents to have a baseline care plan.
Failure to Follow Oxygen Orders and Develop Psychotropic Care Plans
Penalty
Summary
The facility failed to implement the plan of care for one resident with COPD who had a care plan focused on oxygen therapy related to shortness of breath. The care plan directed staff to administer oxygen as ordered, but observations showed the resident receiving oxygen at 3 LPM via nasal cannula from an oxygen concentrator and later at 2.5 LPM via nasal cannula. The DON reviewed the physician orders and confirmed the ordered oxygen rate was 2 LPM via nasal cannula. The facility also failed to develop comprehensive person-centered care plans for two residents receiving psychotropic medications. One resident had diagnoses including dementia, hoarding disorder, and major depressive disorder, and the MAR showed mirtazapine 15 mg at bedtime for weight loss, but the care plan had no focus area or interventions for antidepressant use. Another resident had schizophrenia, and the MAR showed Seroquel 25 mg at bedtime related to schizophrenia, but the care plan had no focus area or interventions for antipsychotic use. The MDS Coordinator and DON confirmed that both residents did not have active care plans addressing their psychotropic drug use.
Oxygen Therapy Administered Without Correct Orders and Equipment Cleanliness
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with COPD when R19 was observed receiving O2 by nasal cannula at 3 LPM and later at 2.5 LPM, although the physician order was for 2 LPM. During both observations, the oxygen concentrator was covered with dust and debris. The DON later confirmed the ordered flow rate was 2 LPM, and an LPN confirmed the concentrator was set at 2.5 LPM and was covered with dust and debris. The LPN stated that nurses and Certified Medication Aides were responsible for making sure the oxygen concentrator was clean. The facility also failed to ensure there was a physician's order for O2 before administering it to R57. R57 had diagnoses including COPD and acute and chronic respiratory failure with hypoxia and hypercapnia, and was observed receiving O2 at 4 LPM by nasal cannula from an oxygen concentrator on two occasions. Review of the physician orders showed no order for O2 therapy. The DON confirmed that R57 was receiving O2 from an oxygen concentrator and that there were no orders for oxygen administration, stating her expectation was for the admission nurse to reconcile all medication orders and transcribe them in the system.
Failure to Follow TBP and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure staff followed infection-control practices for Transmission-Based Precautions in one resident room that had TBP signage and PPE on the door. On 12/21/2025 at 11:41 am, a CNA entered the room without putting on PPE and then exited without using hand hygiene. At 11:44 am, a housekeeper entered the same room without putting on PPE, swept the floor in the resident room, and walked in and out of the room while emptying the dustpan. During interviews, the CNA stated she thought PPE was only needed when doing something to the resident, not just when entering the room. The housekeeper confirmed the TBP signage and PPE on the door and stated she forgot to put on PPE when entering the room. The ICP stated staff were required to follow the instructional signage on TBP room doors, put on PPE before entering the room, and use hand hygiene upon exiting. The ADON and DON stated staff should put on PPE when entering TBP rooms and perform hand hygiene when entering and exiting resident rooms.
Deficiency in Puree Diet Preparation and Portion Control
Penalty
Summary
The facility failed to ensure that recipes for the puree diet were followed, compromising the nutritional value of meals served to residents. During an observation of puree food preparation, it was noted that the Dietary Manager (DM) did not measure the portions of beef and broccoli before blending them, nor did they measure the amount of beef broth added. This resulted in an unmeasured and potentially inadequate nutritional composition of the puree diet served to residents. The DM admitted to not following the recipe for pureed chicken stir fry and was unable to specify the correct portion sizes for residents on puree or regular diets. Interviews with the DM and another dietary staff member revealed a lack of knowledge regarding portion sizes and the nutritional content of meals served. The DM could not identify the appropriate scoop sizes for serving, which is crucial for ensuring residents receive the necessary nutritional intake. The facility's Administrator confirmed that dietary staff are expected to know portion sizes to meet residents' nutritional needs, indicating a gap in training and knowledge within the dietary department.
Failure to Obtain Required Signatures for POLST Documents
Penalty
Summary
The facility failed to obtain a concurring physician's signature for a Physician Order for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) documents for two residents, R1 and R10. For R1, the facility did not ensure that the resident was cognitively intact before signing the POLST document indicating DNR status. R1 was admitted with severe cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. Despite this, R1 signed the POLST form, which only had one physician's signature, contrary to the requirement for a concurring physician's signature when the patient is a candidate for non-resuscitation. For R10, the facility failed to ensure that Power of Attorney (POA) documents were obtained during the implementation of the POLST document. R10's POLST form was signed by the resident's brother-in-law, who claimed to be the POA, but there was no documentation in the resident's medical record to support this claim. The POLST form also only had one physician's signature, lacking the required concurring physician's signature. Interviews with facility staff, including the Social Services Director (SSD) and the Director of Nursing (DON), revealed a lack of understanding and adherence to the proper procedures for completing POLST documents, particularly when two physician signatures are required. The Administrator confirmed the deficiencies, acknowledging that R1's severe cognitive impairment should have precluded them from signing the POLST document. The Administrator also noted that the POLST documents should have all necessary documentation to ensure residents' preferences are honored. The MDS Clinical Reimbursement Coordinator (CRC) confirmed R1's cognitive impairment, indicating that R1 was not capable of understanding or signing the POLST document with full comprehension.
Failure to Submit PASARR Level II for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to submit a PASARR Level II for a resident after a new qualifying mental illness diagnosis of schizophrenia was added. The facility's policy requires coordination with the PASARR program and submission of Level II assessments for residents with newly evident serious mental disorders. However, this process was not followed for the resident in question, who was admitted with diagnoses including anxiety disorder and depression, and later diagnosed with schizophrenia. Interviews with facility staff, including the Social Service Director (SSD), Administrator, and Director of Nursing (DON), confirmed the oversight. The SSD acknowledged responsibility for PASARR submissions and confirmed that the resident should have had a Level II PASARR following the new diagnosis. The Administrator and DON also recognized the need for a Level II PASARR based on the resident's condition, indicating a lapse in the expected procedure for handling new qualifying diagnoses.
Failure to Obtain Physician's Order and Clean Oxygen Equipment
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident, identified as R47, who was receiving oxygen therapy. Despite the facility's policy requiring verification of a physician's order for oxygen administration, R47 was observed receiving oxygen therapy without an active order. The resident had a history of Covid-19, pulmonary embolism, and chronic obstructive pulmonary disease (COPD). After returning from a hospital stay, there were no new orders for oxygen administration, yet the resident continued to receive oxygen therapy at the facility. Additionally, the facility did not adhere to its policy on cleaning and disinfection of resident-care equipment. Observations revealed that the oxygen concentrator used by R47 was covered with dust, indicating it had not been cleaned as required. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the lack of active oxygen orders and the unclean state of the oxygen concentrator. The ADON acknowledged that the oxygen orders should have been updated upon the resident's return from the hospital, and the DON confirmed that nurses were responsible for ensuring the cleanliness of the oxygen concentrators.
Infection Control Breach During Eye Drop Administration
Penalty
Summary
The facility failed to adhere to infection control practices during the administration of ophthalmic drops to a resident, identified as R12. The facility's policy on the installation of eye drops, dated November 2017, requires handwashing, the use of gloves, and proper disposal of gloves followed by handwashing. However, during an observation of medication administration, an LPN did not sanitize the bedside table or use a barrier before placing the bottle of ophthalmic drops on it. The LPN washed her hands but did not wear gloves while administering the drops to the resident. After administering the drops, the LPN did not wash or sanitize her hands before continuing with the medication pass. The LPN justified not wearing gloves by stating that residents sometimes have reactions to them. The Director of Nursing confirmed that the correct procedure involves handwashing and wearing gloves to prevent cross-contamination.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Church Home Rehabilitation And Healthcare | 9.6 mi | ★★★★★ | 0 | 0 |
| Oaks Nursing Home, Inc, The | 10 mi | ★★★★★ | 0 | 0 |
| Summerhill Elderliving Home & Care | 10.4 mi | ★★★★★ | 15 | 0 |
| Roberta Trails Of Journey Llc | 14.3 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - The Lodge, Llc | 14.7 mi | ★★★★★ | 7 | 0 |
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