Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Knoll Path Of Journey Llc during CMS and state inspections, most recent first.
Kitchen sanitation and food safety practices were not maintained as required. Staff observed a dirty vent grate, a contaminated fan pointed toward clean dishes, a brown substance on a dry storage wall, and opened cans stored next to the ice machine. In addition, a dishwasher and a dietary aide with facial hair were observed without beard restraints, despite knowing hair restraints were needed to prevent contamination.
Improper Outdoor Refuse and Dumpster Area Maintenance: The facility failed to keep the outdoor garbage and refuse area sanitary. Surveyors observed overflowing cardboard boxes in an uncovered trash receptacle, a sink left on the dumpster platform, and bread trays on the ground near the outdoor freezer unit with a trash lid on top. The Administrator confirmed the observations and stated the items came from a Central Supply delivery and a kitchen modification project.
Improper Foley catheter care was observed for a resident with a Foley related to a stage 4 sacral pressure ulcer. A CNA emptied the catheter bag, left it above bladder level, did not perform hand hygiene, reused the same gloves and wipe, cleaned the labia incorrectly, and wiped the catheter tubing from distal to proximal. The LPN, Infection Preventionist, and DON confirmed the expected Foley care process required hand hygiene, proper PPE, and clean wipes or washcloths with front-to-back technique and aseptic care.
Respiratory equipment and oxygen administration were not maintained correctly for several residents. Oxygen concentrator filters were visibly dirty and covered with dust and lint for residents receiving O2 via NC, a resident with a trach lacked an extra trach tube at the bedside, and another resident’s oxygen tubing was disconnected from the humidifier bottle while the concentrator was set above the ordered flow rate, leaving the resident without oxygen and with a low SpO2 reading.
Surveyors found that staff did not consistently label, date, or discard expired and opened food items in both refrigerated and dry storage areas, and did not always follow recipes for pureed foods. Expired and unlabeled foods were observed, and the CDM confirmed that staff were responsible for these tasks but had not followed procedures, potentially affecting 102 residents on oral diets.
Staff did not consistently perform hand hygiene when entering and exiting resident rooms, despite being trained and having access to operational hand sanitizer dispensers. Multiple CNAs admitted to forgetting hand hygiene during care, and the facility's policy requiring hand hygiene to prevent infection was not followed.
Kitchen Sanitation and Food Safety Lapses
Penalty
Summary
The facility failed to maintain the kitchen environment in a safe, clean, and sanitary manner in accordance with its Food Safety Requirements policy. During an initial kitchen tour, a ventilation grate under the three-compartment sanitation sink was observed with a significant accumulation of gray particulate matter, five opened cans of diced peaches with juices were sitting next to the kitchen ice machine, and a brown substance was present on the wall of the dry storage area by the shelving for canned goods. The Administrator confirmed each of these observations, and the Food Service Manager later confirmed the dirty ventilation grate had the potential for food contamination and stated she was unsure who was responsible for cleaning the grates. Additional observations showed dietary staff were not consistently following food safety practices. A dishwasher with facial hair was observed without a beard restraint, despite stating he knew facial hair restraints were important to prevent contamination of food and food surfaces. A fan used to dry clean dishes had a significant accumulation of gray particulate matter on its grill and was pointed toward clean dishes in the dishwasher area. A dietary aide with facial hair was also observed without a beard restraint until the issue was brought to the Food Service Manager's attention. The Administrator stated she expected all parts of the kitchen to be clean and in good repair, items to be properly labeled, dated, and stored, and staff to be trained and competent in maintaining a clean and safe kitchen environment.
Improper Outdoor Refuse and Dumpster Area Maintenance
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. During the initial tour of the kitchen area, the Administrator observed cardboard boxes overflowing from a gray trash receptacle without a lid in the outside refuse area. The Administrator confirmed the boxes were improperly disposed of and uncovered, and stated they came from a Central Supply Department delivery on 05/15/2026 and were normally broken down by the Central Supply Manager for disposal. Additional observations in the dumpster area included a sink lying on the dumpster platform next to the dumpster, which the Administrator confirmed had been removed from the kitchen by the ice machine on 05/15/2026 and left there by Maintenance while creating a secondary food preparation station. Three bread trays were also observed on the ground propped against the outdoor freezer unit with a trash lid on top. The Administrator confirmed the observation but was unclear why the racks were situated in the area. During a later interview, the Administrator and FSM stated the dumpster and refuse areas were discussed in a QAPI meeting and that staff would be trained and complete competencies in maintaining a clean and safe environment.
Improper Foley Catheter Care
Penalty
Summary
Catheter care was not performed using proper cleaning technique for a resident with a Foley catheter. The resident had a Foley catheter related to a stage 4 sacral pressure ulcer and was dependent on staff for toileting, hygiene, showering, and bathing. During observation, the CNA was already in the room after completing incontinence care for the roommate, stated the resident was wet and the catheter was leaking, and then emptied the catheter bag while leaving it above bladder level and leaving the resident exposed. The CNA returned with the same gloves without performing hand hygiene, used wipes from the bedside table, and cleaned the outer labia from front to back but then trailed back to the front with the same wipe. The CNA then used the same wipe to clean the Foley tubing from distal to proximal toward the urinary meatus. When interviewed, the LPN and Infection Preventionist confirmed the expected process was hand hygiene, proper PPE, and cleaning the labia and catheter with clean wipes or washcloths using front-to-back technique and a new clean wipe for the catheter. The DON also confirmed that further education was needed for CNAs on catheter care and stated that all tubing should be secured with a securement device and Foley care should be aseptic and performed every shift. The facility policy required wiping from front to back with a clean cloth, using a new part of the cloth or a different cloth for each side, and then using a new moistened cloth to wipe the catheter from the urinary meatus outward.
Respiratory Equipment and Oxygen Administration Failures
Penalty
Summary
The facility failed to maintain respiratory equipment and supplies in proper condition for residents receiving oxygen therapy. Observations showed that oxygen concentrator filters for R5, R41, and R101 were visibly dirty, with dust and lint accumulated on the filters while the equipment remained in use. R5 was receiving oxygen at 2 LPM via nasal cannula from an oxygen concentrator, and the dirty filter was observed on multiple occasions. R41 was also receiving oxygen at 2 LPM via nasal cannula from an oxygen concentrator with a visibly soiled filter. R101 was receiving oxygen at 3 LPM via nasal cannula from an oxygen concentrator, and the filter remained visibly covered with dust and lint during repeated observations. R13, who had diagnoses including tracheostomy status and chronic respiratory failure with hypoxia, was observed lying in bed breathing through a tracheostomy tube with oxygen bled in at 2 LPM. The oxygen concentrator was dirty, and there was no additional tracheostomy tube at the bedside for emergency use. During a later observation, the same conditions were again present. An LPN confirmed the dirt on the oxygen concentrator surface and the absence of an extra tracheostomy tube at the bedside, and stated that an extra trach tube should always be available for emergency use. R23, who had diagnoses including COPD, respiratory failure with hypoxia, diastolic heart failure, and obstructive sleep apnea, was ordered oxygen at 2 LPM via nasal cannula continuously to keep SpO2 above 92%. During an observation and interview, the resident stated there was no air coming through the nasal cannula. The oxygen concentrator was covered with a blanket and a lift pad, and the tubing from the concentrator to the humidifier bottle was not attached. The resident was not receiving oxygen, and the measured SpO2 was 88%. The LPN confirmed that the concentrator was set at 3.5 LPM instead of the ordered 2 LPM and stated that oxygen flow was checked every shift.
Failure to Properly Label, Date, and Discard Food Items in Storage
Penalty
Summary
Surveyors identified that the facility failed to follow its own policies regarding the labeling, dating, and discarding of food items in both refrigerated and dry storage areas. During multiple observations, expired food items such as pasta salad, lemon tea thickener, and cut lettuce were found in the walk-in refrigerator. Additionally, several food items, including tomato bisque soup, waffles, broccoli florets, chicken patties, and cornbread stuffing, were found either unsealed, undated, or unlabeled. The Certified Dietary Manager (CDM) confirmed that all staff were responsible for labeling and dating items before storage, but these procedures were not consistently followed. Further observations revealed that posted menus were out of date and that alternate menus were being offered. The CDM also acknowledged the use of Styrofoam takeout containers due to a broken dishwasher, with maintenance responsible for ordering the necessary part. The facility's policy required the use of the FIFO (first in, first out) method for food storage, but this was not consistently implemented. These deficiencies had the potential to affect 102 residents receiving an oral diet.
Failure to Ensure Consistent Hand Hygiene by Staff
Penalty
Summary
Staff failed to consistently perform proper hand hygiene during resident care, as observed on multiple occasions. Certified Nursing Assistants (CNAs) were seen entering and exiting resident rooms without using the alcohol-based hand sanitizer dispensers, which were operational and adequately supplied. One CNA entered a room in response to a call light without performing hand hygiene, while another left and re-entered a room with clean linens without using hand sanitizer. A third CNA also entered a resident's room without hand hygiene. These lapses occurred despite the facility's policy requiring hand hygiene to prevent the spread of infection. Interviews with the involved CNAs revealed that they had received in-service training on hand hygiene from the Infection Preventionist (IP) nurse and were aware of the facility's expectations. However, they admitted to sometimes forgetting to perform hand hygiene, especially when in a hurry. The IP nurse and Director of Nursing (DON) confirmed that staff had been instructed on proper hand hygiene procedures, including the use of soap and water after personal care and alcohol gel when entering and exiting resident rooms.
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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 Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Carrollton | 1.1 mi | ★★★★★ | 4 | 0 |
| Carrollton Crossing Of Journey Llc | 4.2 mi | ★★★★★ | 14 | 0 |
| Carrollton Manor, Incorporated | 5.3 mi | ★★★★★ | 24 | 0 |
| Haralson Nsg & Rehab Center | 10 mi | ★★★★★ | 3 | 0 |
| Countryside Post Acute | 16.3 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.