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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stone Mountain Run Of Journey Llc during CMS and state inspections, most recent first.
Kitchen equipment was observed with visible contamination, including a dirty ice machine with tan buildup inside and an off-white drip on the lid, as well as two portable air conditioners with a thick black flaky substance blowing from the units. One air conditioner was blowing toward the food line, and the Dietary Manager and District Manager confirmed the conditions.
Dusty PTAC Filters in Multiple Resident Rooms: Surveyors observed an excessive gray buildup on PTAC vent filters in multiple resident rooms across several halls. The RVPO and Administrator confirmed the issue in one room, and the RMD later acknowledged the dust had been present for 2 to 3 months and that he did not believe the PTAC units were cleaned during the HVAC PTAC task log marked complete on time.
The facility failed to develop comprehensive care plans for two residents. One resident was receiving continuous oxygen and nebulizer treatments for respiratory failure, but oxygen therapy was not addressed on the care plan and staff confirmed there was no oxygen order in place. Another resident had severe cognitive impairment and spoke Vietnamese, but the care plan did not identify communication needs despite staff noting language and communication concerns.
Failure to Provide Nail Grooming ADL Care: Four residents with cognitive and physical impairments were observed with long, jagged, dirty fingernails despite care plans calling for clean, well-groomed appearance and no documentation of refusal for personal hygiene. The residents stated they could not care for their nails themselves or did not recall when they were last groomed, and staff interviews confirmed CNAs were responsible for nail care during showers for non-diabetic residents.
A resident with dysphagia, COPD, and a BIMS score of 14 had a 16 fl oz bottle of 91% isopropyl alcohol and a 6.2 oz automatic room scent spray observed at the bedside in a semi-private room. Surveyors observed the items on more than one occasion, and an LPN/unit manager verified their presence before removing them; the Administrator stated the items should not have been in residents' rooms.
A resident with respiratory failure and moderate cognitive impairment was receiving continuous oxygen, but the EMR contained no physician order for oxygen. Staff observed the resident on oxygen at 3 L and later at 2 L via nasal cannula, and RN II confirmed there was no oxygen order in the chart. The DON and Administrator stated that residents on oxygen should have an order for the oxygen rate.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was found with medication left at the bedside without a documented assessment for self-administration. The resident was unable to identify the medication, and staff interviews revealed uncertainty about whether the required assessment had been completed, despite facility policy and staff education prohibiting this practice without proper evaluation.
Staff did not immediately report an allegation of potential sexual abuse between two cognitively impaired residents to the Administrator, as required by facility policy. Instead, the incident was reported the following day, delaying notification to the State Survey Agency and the start of the investigation. The Director of Nursing acknowledged the reporting delay, and the Administrator confirmed the sequence of events.
A resident's air mattress was found to be much smaller than the bed frame, leaving a large section of the frame exposed and creating a risk of limb entrapment. Despite staff acknowledging the hazard and reporting it to maintenance, the issue was not corrected over several days, and no bed assessment was documented in the resident's record. Facility policies requiring immediate correction and regular inspection of equipment were not followed.
A resident over 65 did not have documented evidence of receiving the appropriate pneumococcal vaccine, and the consent form was incomplete, with neither vaccine option circled. There was also no documentation that the resident or their representative received education about the PCV20 or PCV21 vaccines, and the DON confirmed the consents did not follow current CDC guidelines.
Kitchen Equipment Contamination and Poor Food Safety Practices
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen environment and to promote safe food handling practices. Review of the facility policy titled Food Safety Requirements showed that staff were expected to follow safe hygiene practices to prevent contamination of foods and to clean and sanitize the internal components of the ice machine according to manufacturer guidelines. On observation, the ice machine in the kitchen had a build-up of a tan, thick substance on the top and bottom inside surfaces, along with an off-white, tan drip on the left side of the front lid. The Dietary Manager confirmed the build-up inside the unit, and the District Manager later confirmed the same condition. The report also documented two portable air conditioners in use in the kitchen with a thick black flaky substance blowing from the units, including one unit blowing toward the food line. The Dietary Manager confirmed the build-up on the air conditioners and that the unit was blowing toward the food tray line.
Dusty PTAC Filters in Multiple Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing packaged terminal air conditioner (PTAC) units and vent filters to accumulate a dusty grayish buildup in resident rooms across six halls, including rooms 201, 208, 221, 316, 401, 405, 407, 411, 413, 507, 508, 511, 512, 602, 606, 611, 701, and 713. The deficiency was identified during observations on the 200, 300, 400, 500, 600, and 700 halls, where surveyors noted an excessive amount of gray fuzzy substance on pull-out vent filters in multiple rooms. Facility documentation titled Direct Supply TELS showed HVAC/PTAC instructions requiring the air filter to be removed or opened for inspection and cleaned if dirty. During a tour with the RVPO and Administrator, the PTAC unit in one room was confirmed to have a grayish buildup on the filter, and both acknowledged the issue and agreed cleaning would be done right away, though they declined to continue the tour of the other rooms. The Administrator stated the PTAC units were inspected weekly and cleaned monthly, and also noted that the condition of the filter posed a risk of respiratory complications for residents. The Regional Maintenance Director later confirmed, after viewing images of dust accumulation in several rooms, that the buildup had been present for two to three months and stated he had performed cleaning on 02/26/2026, but did not believe he was able to clean the PTAC units during the task log marked completed on time for HVAC PTACs.
Care plan failed to address oxygen therapy and communication needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for two sampled residents. R101, who was admitted with diagnoses including hypertension, respiratory failure, generalized anxiety, and seizures, had a quarterly MDS showing moderate cognitive impairment, dependence for most ADLs, and shortness of breath when lying flat. Although the resident was receiving continuous oxygen at 3 LPM and nebulizer treatments, the care plan initiated on 01/24/2026 and last reviewed on 03/31/2026 did not identify any respiratory issues or oxygen therapy. The MDS also did not indicate that the resident was receiving oxygen, and staff confirmed during observation that R101 was on oxygen continuously without an oxygen order in place. R108, who was admitted with diagnoses including encephalopathy, muscle wasting and atrophy, and cerebral infarction, had an admission MDS showing severe cognitive impairment and extensive assistance needs for ADLs. The resident's care plan did not identify communication needs. During observation, CNA staff stated that R108 did not talk much but understood, that a communication line was available if needed, and that the resident spoke Vietnamese and could say some words in English. The SW stated that communication should have been on the resident's care plan.
Failure to Provide Nail Grooming ADL Care
Penalty
Summary
The facility failed to ensure ADL care related to nail grooming was provided for four sampled residents who required assistance with personal hygiene. Review of the facility policy stated that residents’ abilities in ADLs should not deteriorate unless unavoidable and that residents unable to perform ADLs should receive necessary services to maintain grooming and personal hygiene. The cited residents were identified as having diagnoses and functional impairments that affected their ability to complete personal hygiene tasks, and their care plans included goals to appear clean, well-groomed, and dressed. R44 was admitted with diagnoses including muscle weakness, lack of coordination, dementia, and behavioral disturbances. His MDS showed severe cognitive impairment and need for partial to moderate assistance with personal hygiene. During observations, his fingernails were repeatedly noted to be long, jagged, and dirty with visible dark debris. He stated he would trim them himself if he could and later said he would allow staff to provide nail care, but he did not recall when his nails were last groomed. His CNA task sheets showed no documentation of refusal for personal hygiene. R77 was admitted with diagnoses including cerebrovascular disease affecting the left non-dominant side, contracture of the left wrist, reduced mobility, muscle wasting and atrophy, and lack of coordination. His MDS showed moderate cognitive impairment and need for partial to moderate assistance with personal hygiene. He was observed with long, jagged, dirty fingernails with visible dark debris and stated staff would not do them for him and that he could not do them himself. He later said he would allow nail care and wanted it done as soon as possible. His CNA task sheets also showed no documentation of refusal. R124 was admitted with diagnoses including sequelae of cerebral infarction, lack of coordination, need for assistance with personal care, and generalized muscle weakness. His MDS showed moderate cognitive impairment and dependence on staff for personal hygiene. He was observed with excessively long, jagged fingernails and visible dark debris, and he stated he could not recall when they were last cleaned and trimmed but would like them groomed. R144 was admitted with diagnoses including need for assistance with personal care, generalized muscle weakness, quadriplegia, multiple sclerosis, and cognitive communication deficit. Her MDS showed moderate cognitive impairment and substantial assistance needs for personal hygiene. She was observed with excessively long, jagged fingernails and visible dark debris, and later with unchanged nails and remnants of red nail polish. She stated she could not clean or trim them and could not remember when they were last groomed. Her CNA task sheets also showed no documentation of refusal for personal hygiene.
Accident hazards found in resident room
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for one of 59 sampled residents, R9. Review of the facility policy titled, "Accidents and Supervision," stated that the resident environment will remain as free of accident hazards as is possible and that the facility should make a reasonable effort to identify hazards and risk factors for each resident. R9 was admitted with diagnoses including dysphagia, oropharyngeal phase, and COPD. The most recent MDS assessment showed a BIMS score of 14, indicating R9 was cognitively alert and oriented. The care plan dated 12/08/2025 contained no documentation for accident hazards. During the initial screening on 05/04/2026, surveyors observed in R9's room a 16 fl oz bottle of 91% isopropyl alcohol and a 6.2 oz automatic room scent spray on top of a two-tier white plastic storage container. On 05/06/2026, surveyors again observed the same items by R9's bedside in the semi-private room. An LPN/unit manager verified the presence of the alcohol and room scent spray and removed the items from the bedside, stating she had explained the potential accident hazards associated with each item to R9. The Administrator later stated that the identified items should not have been present in residents' rooms.
Missing Physician Order for Resident Receiving Oxygen
Penalty
Summary
The facility failed to obtain a physician order for oxygen for a resident who was receiving continuous oxygen therapy. Review of the resident’s record showed diagnoses including respiratory failure and generalized anxiety, and the quarterly MDS documented moderate cognitive impairment, shortness of breath when lying flat, and no indication that the resident was receiving oxygen in Section O. The care plan did not identify respiratory issues, and the physician’s orders contained no oxygen order. During observation, the resident was seen sitting up in bed eating lunch and stated she was on continuous oxygen at 3 L and had returned to the facility on oxygen after a hospital discharge. A later observation showed the resident resting quietly with oxygen at 2 L via nasal cannula. RN II confirmed the resident was receiving oxygen at 3 L per minute and acknowledged there was no oxygen order in the EMR. The DON and Administrator both stated their expectation that a resident on oxygen should have an order for the oxygen rate.
Failure to Assess Resident for Medication Self-Administration Before Leaving Medication at Bedside
Penalty
Summary
The facility failed to assess whether a resident was clinically appropriate to self-administer medications before leaving medication at the bedside. According to the facility's policy, residents may only self-administer medications after an interdisciplinary team assessment determines it is safe. However, review of the resident's electronic medical record revealed no such assessment was conducted. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, and generalized anxiety disorder, was noted to have a BIMS score of 4 out of 15, indicating severe cognitive impairment. Despite this, a medication cup containing a yellowish liquid was observed at the resident's bedside during breakfast, and the resident was unsure of what the medication was, only stating it was taken every morning and evening. Interviews with the DON and other staff confirmed uncertainty about whether a self-administration assessment had been completed for the resident, and staff acknowledged they had been educated not to leave medications at the bedside without such an assessment. The DON later confirmed that an assessment had been completed and determined the resident was not capable of self-administration, yet the medication was still left at the bedside unattended.
Failure to Timely Report Alleged Sexual Abuse Between Residents
Penalty
Summary
Facility staff failed to immediately report an allegation of potential sexual abuse involving one resident against another to the Administrator, who also served as the abuse coordinator. According to facility policy, all alleged violations involving abuse must be reported to the Administrator and appropriate authorities immediately, but not later than two hours after the allegation is made. In this case, a resident with moderate cognitive impairment informed a nurse that her roommate, who was severely cognitively impaired, had asked her for sex. The nurse moved the alleged perpetrator to another room, but the Administrator was not notified until the following day, resulting in a delay in reporting the incident to the State Survey Agency and initiating an investigation. The records indicate that the resident making the allegation had a history of confabulation, while the accused resident had a care plan for hypersexual behaviors but no documented incidents following medical intervention. The investigation was not started until after the Administrator was informed, and only then were both residents interviewed regarding the incident. The delay in reporting was acknowledged by the Director of Nursing, who stated the allegation should have been reported immediately, and the Administrator confirmed the timeline of notification and subsequent reporting to authorities.
Failure to Ensure Bed Frame and Mattress Compatibility Creates Entrapment Hazard
Penalty
Summary
A deficiency was identified when a resident's air mattress was observed to be significantly smaller than the bed frame, leaving approximately 12 inches of the bed frame exposed. This mismatch created a potential hazard for the resident, as their legs or arms could become trapped in the exposed area during repositioning or care. Multiple observations over several days confirmed that the issue persisted, and both nursing and therapy staff acknowledged the risk. The resident's electronic medical record did not contain any completed bed assessments, and the facility's policies required regular inspections to identify such hazards. Interviews with staff revealed that the issue had been reported to maintenance, but no corrective action had been taken by the time of subsequent observations. The Director of Nursing was not aware of the problem until it was brought to her attention during the survey. Facility policies stated that all hazards should be corrected immediately and that all staff are responsible for reporting defective equipment, but these procedures were not followed in this instance.
Failure to Obtain Accurate Consent and Provide Education for Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident over the age of 65 received accurate consent and education regarding pneumococcal vaccinations in accordance with CDC guidelines and facility policy. Specifically, the resident's electronic medical record did not show evidence of receiving the PCV20 or PCV21 vaccination, and the consent form provided by the facility was incomplete, as neither vaccine option was circled. Additionally, there was no documentation that the resident or their representative was given education about the benefits and potential side effects of the PCV20 or PCV21 vaccines prior to administration. During an interview, the DON, who also served as the Infection Preventionist, confirmed that although an audit for vaccinations was completed and education was provided to the resident's representative, the consents were inaccurate and did not align with current CDC recommendations. This lack of proper consent and education meant the resident and/or representative was not given the opportunity to make an informed decision before the vaccine was administered.
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What surveyors actually found near you
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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 Stone Mountain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pebblebrook Health Center At Park Springs | 2.5 mi | ★★★★★ | 0 | 0 |
| Tucker Operating Company Llc | 2.9 mi | ★★★★★ | 11 | 0 |
| Tucker Park Crossing Of Journey Llc | 3.3 mi | ★★★★★ | 10 | 0 |
| Briarwood Health Center By Harborview | 4.9 mi | ★★★★★ | 1 | 0 |
| Harborview Decatur | 6 mi | ★★★★★ | 0 | 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.