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 Woods At Sparta Of Journey Llc, The during CMS and state inspections, most recent first.
Unsanitary Air Conditioner Above Dish Storage: A window-unit AC located above dish racks with silverware and cups had a buildup of grey, fuzzy substance and black, flaky substance on the vents while it was turned on and blowing across the dishes. The DM confirmed the findings, and the facility's Food Safety Requirements policy defined contamination as the unintended presence of potentially harmful substances.
Failure to complete a PASRR Level II referral for a resident with qualifying mental health diagnoses. The resident had documented depression, anxiety, and PTSD, no dementia or Alzheimer’s disease, and MDS assessments showing little to no cognitive impairment. The record contained no PASRR Level II, and the SSD confirmed the resident had qualifying diagnoses and should have had a submission.
A resident sustained a burn from an unsupervised e-stim treatment, and the facility failed to report or document the incident promptly. Additionally, power strips were improperly placed on the floor and bedside tables, posing hazards to residents. Staff interviews revealed a lack of awareness and communication regarding safety protocols.
A resident suffered a burn on the right leg due to improper use of an e-stim device by physical therapy staff who were not adequately trained. The staff member applied the device and left the room, resulting in the resident experiencing intense burning and removing the device to find burn marks. Interviews revealed that the facility did not provide training or competency checks for the e-stim device, relying on staff's prior schooling. The facility began training after the incident, but the delay in education was unexplained.
The facility's dietary staff failed to follow proper food safety protocols, including preventing wet nesting of steam table pans, storing food off the floor, and correctly using the three-compartment sink for sanitizing dishware. These deficiencies were confirmed by the Dietary Manager and observed during a survey.
A facility failed to maintain a dumpster, resulting in liquid waste leaking onto the ground due to a missing plug. Despite being aware of the issue, the facility's staff, including the DM and IMD, confirmed the ongoing leakage over several days. The Administrator noted the dumpsters were city-owned and lacked a specific waste disposal policy.
The facility failed to maintain effective infection control in its laundry operations. Observations revealed that laundry staff did not use PPE and transported clean linens uncovered, violating facility policies. Interviews indicated a lack of training and awareness among staff and management regarding infection control procedures, leading to potential cross-contamination risks.
A resident in a long-term care facility developed sores on the right lower leg, believed to be from an e-stim machine used during physical therapy. Despite the resident's denial of the sores' origin, the Physical Therapy Assistant documented the observations but failed to communicate them to the nursing staff or the Administrator. Consequently, the physician or Nurse Practitioner was not notified until 11 days later, when the resident's condition had worsened, requiring antibiotic treatment. Interviews revealed a breakdown in communication and documentation, with staff failing to complete an incident report or ensure proper notification.
The facility was found deficient in maintaining a safe, clean, and comfortable environment, with issues such as missing floor tiles, a bare lightbulb, chipped and peeling paint, and discolored ceiling tiles. Interviews revealed a lack of awareness and documentation of these maintenance issues, with the facility in the process of recruiting a permanent Maintenance Director.
The facility did not conduct pre-employment reference checks for eight employees, including key staff like the Administrator and DON, as required by their policy on Abuse, Neglect, and Exploitation. This oversight was confirmed through interviews and a review of employee files, although no abuse or neglect concerns were identified at the time.
Two residents with serious mental disorders were not referred for a PASARR Level II assessment upon admission or within 30 days of a new diagnosis. One resident with PTSD had an incomplete PASARR Level I, and no Level II assessment was conducted. Another resident with multiple diagnoses, including anxiety disorder, had an incomplete PASARR Level I, and no Level II assessment was completed. The responsibility for ensuring these assessments lies with the social worker, who was unavailable for comment.
A resident with schizophrenia was admitted to a facility without a required PASARR Level II assessment, despite facility policy mandating such coordination for mental disorders. The resident's PASARR Level I status was marked as Pending, indicating the need for further assessment, but this was not completed, as confirmed by the DON and Business Office Manager.
The facility failed to develop and implement comprehensive care plans for two residents. One resident did not have a care plan for pain management despite having diabetes with neuropathy and documented pain. Another resident's care plan for oxygen therapy was not followed, despite their need for respiratory support due to conditions like COPD and sleep apnea. These deficiencies were confirmed by the MDS/Care Plan Coordinator and the DON.
A facility failed to update a resident's care plan to reflect a change in code status from Full Code to DNR, as indicated by the POLST document. The MDS Coordinator acknowledged the oversight, and the DON explained that the SSD was responsible for reporting code status changes to the MDS Coordinator.
The facility failed to provide proper respiratory care for two residents. One resident did not receive continuous oxygen as ordered, with the equipment left exposed. Another resident's nebulizer mouthpiece was improperly stored, increasing infection risk. Staff were aware of the protocols but did not comply.
A facility failed to implement a 14-day stop date for a resident's PRN Ativan prescription, as required by their policy. The medication, used for anxiety, was administered multiple times over an extended period without a documented rationale for extending the order. The DON admitted the oversight despite audits to ensure compliance.
The facility did not follow established menus and failed to notify the RD of meal substitutions, affecting residents on mechanical soft ground and puree diets. Instead of the posted menu, residents received meals with unapproved substitutions, such as brown gravy on chicken and mashed potatoes instead of puree cabbage. The RD was not informed of these changes, contrary to facility policy.
The dietary staff failed to follow the standardized recipe for fried chicken, affecting nine residents who required puree and mechanical soft ground consistencies. Instead of using fried chicken as indicated on the menu, plain steamed diced chicken was used, compromising the nutrient value of the meal. The Dietary Manager and Registered Dietitian were unaware of this substitution, leading to a deficiency in meal preparation.
Unsanitary Air Conditioner Above Dish Storage
Penalty
Summary
The facility failed to ensure sanitary conditions in the kitchen. During observation with the Dietary Manager, a window-unit air conditioner located above a countertop with dish racks containing silverware and cups was found to have a buildup of grey, fuzzy substance and black, flaky substance on the vents while it was turned on and blowing across the racks of dishes. The Dietary Manager confirmed the findings during the initial observation and again later the same day when the black, flaky substance was still present in the vents. The facility's policy titled Food Safety Requirements defined contamination as the unintended presence of potentially harmful substances, including microorganisms, chemicals, or physical objects.
Failure to Complete PASRR Level II Referral for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that one resident with qualifying diagnoses was referred to the appropriate state-designated authority for Level II PASRR screening. Review of the resident’s record showed diagnoses of major depressive disorder, anxiety disorder, and PTSD, with no diagnosis of dementia or Alzheimer’s disease. The annual MDS documented that the resident was not currently considered by the state-level II PASRR process to have a serious mental illness or intellectual disability, while also listing active diagnoses of anxiety, depression, and PTSD. The quarterly MDS similarly documented a BIMS score of 15 and the same active diagnoses. The resident’s physician orders included Zoloft 25 mg daily related to PTSD, and the clinical record contained no PASRR Level II. During interview, the Social Services Director confirmed that the resident had diagnoses including PTSD, depression, and anxiety, and stated that there was no submission for a PASRR Level II. The Social Services Director also stated that the resident had qualifying diagnoses for a PASRR Level II submission and should have had one.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure the safety of three residents, resulting in actual harm to one resident, R14, who sustained a burn from an electrical stimulation (e-stim) treatment. The physical therapy staff did not adequately supervise the e-stim treatment, leading to a burn on R14's right leg. Despite the resident's report of the burn to the physical therapy assistant, the incident was not communicated to the nursing staff or documented in the resident's medical record until 11 days later. The resident continued to receive e-stim treatments even after the burn was identified, and the physician was not notified promptly. Additionally, the facility did not maintain a safe environment for residents R14, R15, and R30, as power strips were found on the floor and bedside tables, posing potential hazards. These power strips were used with medical equipment, such as oxygen concentrators and electrical beds, without being properly secured or mounted. Staff interviews revealed a lack of awareness and communication regarding the proper placement and safety requirements for surge protectors. The facility's failure to adhere to its own policies on incident reporting and safety precautions contributed to the deficiencies. The lack of immediate action and communication among staff members regarding the burn incident and the improper use of power strips demonstrated a significant oversight in ensuring resident safety and compliance with established protocols.
Lack of Training Leads to Resident Harm from E-Stim Device
Penalty
Summary
The facility failed to ensure that physical therapy staff were adequately informed or educated before applying an electronic medical device for electrical stimulation treatment (e-stim) on a resident, resulting in actual harm. The incident involved a resident who sustained a burn on the right leg with 100% slough in the wound bed after a physical therapy staff member applied the e-stim device and left the room. The resident, who was cognitively intact, reported that the device began to burn intensely, prompting him to remove it and discover three burn marks. The resident expressed concern that staff were using residents as test subjects without proper training. Interviews with facility staff revealed a lack of training and competency checks for the e-stim device. The Physical Therapy Manager admitted that the therapy staff had not received training or education on the device within the facility, assuming that their schooling sufficed. The Physical Therapy Assistant confirmed the absence of formal training, relying on her school training and personal experimentation. The Administrator acknowledged the need for skill checks to ensure staff competency, and the Regional Rehabilitation Manager confirmed that no training was provided before the incident. The facility began educating the physical therapy department after the incident, but the reason for the delay was not provided.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The dietary staff at the facility failed to adhere to proper food safety and sanitation protocols, as observed during a survey. The staff did not prevent wet nesting of steam table pans, which can lead to bacterial growth. During an inspection, it was found that the inside of the top pans in stacks of steam table pans were wet, indicating they were not completely air-dried before stacking. The Dietary Manager confirmed this observation and acknowledged that the pans should have been air-dried completely before being stacked. Additionally, the facility did not store food items properly in the dry storage area, as cases of food were found directly on the floor. The Dietary Manager admitted that the food items were left on the floor due to a recent grocery delivery and a lack of time to store them properly. Furthermore, the staff did not follow the correct procedure for using the three-compartment sink for sanitizing dishware. A dietary staff member was observed not immersing dishware in the sanitizing solution for the required 60 seconds, which was confirmed by the staff member and the Dietary Manager.
Improper Dumpster Maintenance Leads to Waste Leakage
Penalty
Summary
The facility failed to properly maintain one of its two dumpsters, leading to a deficiency in waste management. Observations revealed that the dumpster closest to the building was missing a plug at the bottom, resulting in a liquid substance actively dripping onto the asphalt ground. This issue was first observed on 8/9/2024 and continued to be present during subsequent observations on 8/10/2024 and 8/11/2024. The Dietary Manager confirmed the absence of the plug and the active leakage during interviews conducted on these dates. The facility's Administrator and Interim Maintenance Director were made aware of the issue, with the Administrator noting that the dumpsters were city-owned and maintained, and that there was no existing policy regarding dumpsters or waste disposal. The Interim Maintenance Director confirmed that the plug likely dislodged during the last garbage pick-up and had contacted the waste management company to request a replacement. Despite these communications, the issue persisted over several days, indicating a lapse in timely corrective action.
Infection Control Deficiency in Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in the handling, storage, and processing of linens. During a tour of the laundry area, it was observed that the industrial washer had accumulations of chemical residue and dust, and the laundry staff was not using personal protective equipment (PPE) while handling both dirty and clean laundry. Additionally, clean clothing was found hanging on an uncovered rack, ready for distribution, which is against the facility's infection control policies. Interviews with the laundry staff and management revealed a lack of awareness and training regarding infection control procedures. Laundry Aide GG admitted to not wearing PPE and was unaware of the requirement to cover clean clothing racks. The Laundry Manager, who was new to the position, also lacked training and was unaware of the need to cover clean clothing racks or the requirement for staff to wear PPE. The Director of Nursing confirmed that all linen should be covered before leaving the laundry and that staff should wear gloves and gowns when handling soiled linen. Further observations showed that clean linen was transported in uncovered baskets and placed next to dirty linen carts, which violates the facility's policy of keeping clean and dirty linens separate. Interviews with other laundry aides confirmed that they had never covered laundry during transport and did not wear PPE when handling contaminated or clean linen. The Infection Prevention Nurse and the Administrator reiterated the importance of separating clean and dirty linen and the requirement for PPE, highlighting a systemic issue in the facility's infection control practices.
Failure to Timely Notify Health Agent of Resident's Burn
Penalty
Summary
The facility failed to timely notify the health agent of a significant change related to a burn for a resident, identified as R14, which was a deficiency found during the survey. The facility's policy requires notifying the resident, their physician, and a family member or legal representative when there is a significant change in the resident's condition. In this case, R14, who was cognitively intact with a BIMS score of 14, developed sores on the right lower leg, believed to be from an e-stim machine used during physical therapy. Despite the resident's denial of the sores' origin, the Physical Therapy Assistant (PTA) documented the observations but failed to communicate them to the nursing staff or the Administrator. Consequently, the physician or Nurse Practitioner was not notified until 11 days later, when the resident's condition had worsened, requiring antibiotic treatment. Interviews with facility staff revealed a breakdown in communication and documentation. The PTA informed the Physical Therapy Manager of the burn, but neither completed an incident report nor ensured the nursing staff was aware. The Assistant Director of Nursing confirmed the absence of documentation or an event report related to the burn in the electronic medical record. The Physical Therapy Manager admitted to assuming the PTA had reported the incident to nursing and acknowledged the oversight in not following up. The Medical Director was aware of the burn but uncertain about the timeliness of the notification, emphasizing the need for immediate reporting and frequent monitoring of such injuries.
Deficiencies in Facility Maintenance and Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in several resident rooms and a common area, as observed during a survey. Specific deficiencies included missing floor tiles in multiple rooms, a bare lightbulb without a cover in a shared restroom, chipped paint on baseboards, peeling paint exposing drywall, and discolored ceiling tiles in the Resident Dining Room. These issues were identified through observations conducted on different dates and times, highlighting the facility's inability to adhere to its own policies on maintenance and preventative maintenance. Interviews with the facility's Administrator, Interim Maintenance Director, and Corporate Director of Procurement, Information Technology, and Maintenance revealed a lack of awareness and documentation regarding the maintenance issues. The Administrator confirmed the need for repairs and expressed expectations for a home-like environment, while the Interim Maintenance Director admitted to conducting daily observational rounds without documentation. The Corporate Director acknowledged the need for timely repairs and was in the process of finding matching tiles for the missing ones. The facility was also in the process of recruiting a permanent Maintenance Director.
Failure to Conduct Pre-Employment Reference Checks
Penalty
Summary
The facility failed to conduct pre-employment reference checks for eight out of 60 employees, as required by their policy on Abuse, Neglect, and Exploitation. This policy mandates that potential employees undergo background, reference, and credentials checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. The absence of these checks was discovered during a review of employee files, which revealed that key staff members, including the Administrator, Director of Nursing, and several nurses, were hired without the necessary reference checks. Interviews with the Business Office Manager and the Administrator confirmed the lack of documentation for these reference checks. The Business Office Manager, who was temporarily covering for the Human Resource Director, was unable to locate the required documents. The Administrator acknowledged that the Human Resource Director was responsible for ensuring the completion and maintenance of new hire documents, including reference checks. Despite the deficiency, there were no identified concerns related to abuse or neglect within the facility at the time of the report.
Failure to Conduct PASARR Level II Assessments
Penalty
Summary
The facility failed to ensure that two residents with serious mental disorders were referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. Resident R34 was admitted with a diagnosis of PTSD, but the PASARR Level I request did not document this diagnosis, and no PASARR Level II assessment was conducted. The Director of Nursing confirmed the absence of a PASARR Level II in R34's clinical record and acknowledged that the PASARR Level I should have included the PTSD diagnosis. The Social Service Director, responsible for reviewing PASARR Level I and resident diagnoses, was unavailable for comment. Resident R35 was admitted with diagnoses including dementia, depression, anxiety disorder, and delusional disorder. However, no PASARR Level II assessment was completed, and the PASARR Level I assessment was incomplete, with sections left blank. Interviews with the Business Office Manager and the Director of Nursing revealed that the responsibility for ensuring a PASARR Level II assessment lies with the social worker, who was also unavailable for an interview. The Director of Nursing noted that R35's diagnosis of anxiety disorder warranted a PASARR Level II assessment.
Failure to Complete PASARR Level II Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident with a serious mental disorder was referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. The resident, identified as R19, was admitted with a diagnosis of schizophrenia, which was documented in the electronic medical record and the Minimum Data Set (MDS). Despite this, the facility did not have a PASARR Level II assessment on file for the resident, as confirmed by the Director of Nursing (DON) and the Business Office Manager. The facility's policy requires coordination with the PASARR program to ensure appropriate care for residents with mental disorders. However, the Social Services Director, responsible for tracking PASARR screening status, did not ensure a Level II assessment was completed for R19. The PASARR Level I request, dated 5/5/2017, indicated a diagnosis of schizoaffective disorder, and the status was marked as Pending, suggesting the need for a Level II assessment. The absence of this assessment was verified by the DON, who acknowledged the potential risk of the resident not receiving necessary services.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, R14 and R15, as required by their policy. For R14, the facility did not create a care plan addressing pain management despite the resident's documented diagnoses of type 2 diabetes mellitus with diabetic neuropathy and generalized muscle weakness. The resident's quarterly MDS indicated the presence of pain, and a physical therapy evaluation outlined a treatment plan to manage this pain. However, the care plan lacked any mention of pain management or the specific diagnosis, which was confirmed by the MDS/Care Plan Coordinator and the Director of Nursing (DON). For R15, the facility failed to implement the care plan for oxygen therapy. The resident's medical record included diagnoses such as acute and chronic respiratory failure, COPD, and obstructive sleep apnea, with the quarterly MDS documenting the receipt of oxygen therapy. Although the care plan noted the risk of respiratory decline and included interventions for respiratory treatments, it was not followed as the resident did not receive oxygen as ordered. This oversight was verified by both the MDS/Care Plan Coordinator and the DON, who acknowledged the care plan was not being adhered to.
Failure to Revise Care Plan for Code Status Change
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in code status. The facility's policy on Comprehensive Care Plans requires that care plans be reviewed and revised by the interdisciplinary team following each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, a review of the resident's care plan revealed that it was not updated to reflect the change from Full Code status to Do Not Resuscitate (DNR), despite the Physician Orders for Life-Sustaining Treatment (POLST) document indicating a change to Allow for Natural Death. The MDS Coordinator acknowledged the oversight during an interview, and the Director of Nursing explained that the Social Service Director was responsible for handling code status changes and reporting them to the MDS Coordinator.
Deficient Respiratory Care Practices
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident with acute and chronic respiratory failure, heart failure, COPD, and obstructive sleep apnea, the facility did not administer oxygen as ordered. Observations revealed that the resident was not receiving the prescribed continuous oxygen, and the oxygen tubing and nasal cannula were left exposed to the environment. There was no documentation of the resident refusing or removing the oxygen, despite the order for continuous administration. For another resident with dyspnea and COPD, the facility did not properly store the nebulizer mouthpiece. Observations showed that the nebulizer cup and mouthpiece were left unbagged and exposed to the environment. Interviews with staff confirmed awareness of the requirement to store respiratory equipment in a plastic bag to prevent infection, yet the equipment was not stored properly. The resident reported that the storage bag had been missing for a few days, and staff interviews confirmed the lack of compliance with storage protocols.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure a stop date was implemented for psychotropic medications, specifically for a resident prescribed Ativan for anxiety. The facility's policy requires that PRN psychotropic drugs have a stop date not exceeding 14 days unless the attending physician documents a rationale for extending the order. However, a review of the resident's physician orders revealed an indefinite end date for Ativan, which was administered multiple times over a period exceeding 14 days. The Director of Nursing acknowledged that the oversight occurred despite audits conducted to ensure compliance with the policy.
Failure to Follow Established Menus and Notify RD of Substitutions
Penalty
Summary
The facility failed to adhere to established menus and did not notify the Registered Dietitian (RD) of meal substitutions, affecting residents on mechanical soft ground and puree diets. The facility's policy, titled Therapeutic Diet Orders, mandates that residents receive foods in the appropriate form and nutritive content as prescribed by a physician or assessed by the interdisciplinary team. However, during an observation, it was noted that the lunch meal served did not match the posted menu. Instead of fried chicken, black eye peas, collard greens, and cornbread, residents on a mechanical soft ground diet received ground plain chicken with brown gravy, boiled cabbage, blackeye peas, and cornbread. Residents on a puree diet received plain puree chicken with brown gravy, puree blackeye peas, and mashed potatoes. Interviews revealed that the Dietary Manager (DM) did not notify the RD of several menu changes, including the addition of brown gravy to the chicken, the substitution of mashed potatoes for puree cabbage, and the omission of pureed cornbread. The RD confirmed that she was only informed about the substitution of cabbage for collard greens. The DM admitted to not having the option to purchase chicken gravy and using brown gravy instead, as well as not having time to puree cabbage. The RD emphasized that dietary staff should serve the menu as posted and notify her of any modifications, which was not done in this instance.
Failure to Follow Recipe for Fried Chicken
Penalty
Summary
The dietary staff at the facility failed to follow the standardized recipe for fried chicken, compromising the nutrient value of the meal served to residents. The deficiency affected six residents who required puree consistency and three residents who required mechanical soft ground consistency from a total of 40 residents receiving an oral diet. The menu indicated that fried chicken was to be served, but instead, plain steamed diced chicken was used. This practice was observed during a survey, where Dietary [NAME] II was seen using steamed diced chicken instead of fried chicken for the puree consistency meal. The dietary staff member was unaware of the recipe requirements and had been using plain chicken, believing it was acceptable. The Dietary Manager (DM) confirmed the use of plain steamed chicken instead of fried chicken and admitted that the facility's Registered Dietitian (RD) had not been informed of this substitution. The RD expected the dietary staff to follow the recipes and indicated that actual fried chicken should have been used to ensure proper nutrient value and taste. The RD was not aware of the changes made by the dietary staff, and the DM assumed that using any form of chicken would suffice. This lack of communication and adherence to the recipe led to the deficiency in meal preparation.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sparta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sparta Health And Rehabilitation | 5.3 mi | ★★★★★ | 8 | 0 |
| Warrenton Woods Of Journey Llc | 19.2 mi | ★★★★★ | 2 | 0 |
| Atrium Health Navicent Baldwin | 20.8 mi | ★★★★★ | 0 | 0 |
| Gibson Health Opco Llc | 21.6 mi | ★★★★★ | 4 | 0 |
| Heritage Inn Of Sandersville Health And Rehab | 21.7 mi | ★★★★★ | 0 | 0 |
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