Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crossroads Of Flowery Branch Of Journey Llc, The during CMS and state inspections, most recent first.
Two residents with significant medical conditions, including dementia and heart failure, made allegations of staff-to-resident abuse that were reported to facility staff but not reported to administration or the State Survey Agency within the required timeframe. Facility staff, including the DON and SSD, failed to document, report, or investigate these allegations as required by policy, resulting in a lack of appropriate response to the reported incidents.
The facility did not properly identify or investigate allegations of staff-to-resident abuse for two residents. In one case, a resident with dementia and on hospice care reported being hurt by staff, but no investigation was conducted. In another case, a cognitively intact resident was found with bruising, but the investigation lacked interviews with the resident and other residents, and there was no analysis of the cause or staff training on abuse reporting.
Two residents experienced significant weight loss that was not accurately coded in their MDS assessments. One resident with dysphagia lost over 8% of body weight, and another with Parkinson's disease lost over 13% in a month, but these losses were not documented in the MDS. Staff interviews confirmed the omissions, and the DON acknowledged the expectation for accurate MDS coding.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility failed to ensure that two CNAs completed the required in-service training hours, with CNA AA completing only 5.5 out of 6 hours and CNA FF completing 1.15 out of 12 hours. This deficiency was identified during a staff development review. Interviews revealed a lack of awareness and oversight, with management collectively responsible for overseeing in-services but no designated person for the task. The ADON and CNA AA were unaware of the non-compliance, while the DON expected all CNAs to complete their in-service hours to ensure resident safety.
The facility failed to document and communicate resolutions to resident concerns voiced during Resident Council meetings. Despite the policy requiring follow-up, the Activity Director and DON acknowledged that resolutions were not documented, leaving residents unaware of outcomes or grievance procedures.
The facility failed to maintain a safe and homelike environment, with six resident rooms having furniture in disrepair and leaking PTACs. Dressers in several rooms were missing drawers or knobs, and PTACs in other rooms leaked water onto the floors. The Maintenance Director confirmed these issues, citing extreme heat and condensation as causes for the PTAC leaks, and noted challenges in addressing these problems due to working alone.
CNAs in the facility failed to use hand sanitizer between distributing lunch trays to residents, despite being reminded by an RN. The CNAs admitted to forgetting the practice and had not received handwashing training since starting at the facility. The DON confirmed the expectation for proper hand hygiene to prevent infection control issues.
A resident with multiple chronic conditions experienced a significant change in condition, including altered mental status and respiratory distress, leading to transfer to the ED. Despite assessments and actions taken by nursing staff and a nurse practitioner, there was no timely documentation of the change of condition or the events leading to the transfer in the medical record, nurses' notes, 24-hour report, or SBAR report. The deficiency was only identified after surveyor inquiry, prompting late entries.
Failure to Timely Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to facility administration and/or to the State Survey Agency (SSA) within the required two-hour timeframe for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, allegations of being hurt by staff resulting in bruising and wounds were reported to the Social Service Worker (SSW) on two occasions. The SSW reported these allegations to the Administrator and Social Service Director (SSD), but there was no evidence that the facility reported or investigated the incidents as required. The Director of Nursing (DON) and SSD acknowledged awareness of the allegations but did not report or document them, with the DON attributing one bruise to a prior fall and the Administrator expressing personal doubts about the validity of the reports, which led to no investigation or reporting. For the second resident, who had heart failure, kidney failure, depression, hypertension, muscle weakness, and was also on hospice care, complaints of rough treatment by staff were made to both the resident's family and facility staff. A Certified Nurse Aide (CNA) reported to the SSD that the resident alleged a staff member had held her hand too hard and caused pain. The SSD documented the allegation in a daily planner but did not report or investigate the incident, and could not recall the reporting CNA. The Administrator later confirmed a lack of awareness and concern that these issues were not reported or investigated as required. These failures were in direct violation of the facility's policy, which mandates immediate reporting of all alleged violations.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to identify and/or investigate allegations of staff-to-resident abuse for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, there were two separate reports made by a hospice social worker that the resident claimed to have been hurt by staff, resulting in bruising and wounds. These reports were communicated to both the facility Administrator and Social Service Director, but there was no evidence that any investigation was initiated or documented by the facility. The Director of Nursing confirmed that no investigation was conducted, and the Administrator could not locate any report of the allegations, acknowledging that they should have been investigated. For the second resident, who was cognitively intact and had multiple medical conditions, a family friend reported bruising, which was subsequently reported to the Administrator. While an incident report was created and some staff interviews were conducted, there was no documentation that the resident was interviewed, that other residents were questioned, or that the cause of the bruising was analyzed. Additionally, there was no evidence of staff training on reporting or investigating injuries of unknown origin, nor documentation of measures to protect the resident or prevent recurrence. The Administrator admitted to being unaware that the investigation was incomplete and agreed that all such allegations should be thoroughly investigated.
Failure to Accurately Code Significant Weight Loss in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect significant weight loss for two residents. For one resident with dysphagia, weight records showed a loss of 8.73% over a short period, but the quarterly MDS assessment did not document this significant weight loss. The resident's care plan noted a risk for weight loss but did not address the actual significant loss that had occurred. During observation, the resident expressed concerns about being skinny, further indicating awareness of her weight change. For another resident with Parkinson's disease and other brain disorders, weight records indicated a 13.54% loss in one month, but the quarterly MDS assessment failed to code this significant weight loss. Progress notes showed interventions such as appetite stimulation and dietician involvement, and the care plan was revised to note significant weight loss at a later date. Staff interviews confirmed that the MDS assessments for both residents did not reflect the significant weight loss, and the DON acknowledged that the MDS should have included this information.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that two of its Certified Nursing Assistants (CNAs) completed the minimum required in-service training hours during the review period from February 1, 2023, to January 31, 2024. Specifically, CNA AA, who worked part-time, completed only 5.5 hours out of the required 6 hours, and CNA FF, who worked full-time, completed only 1.15 hours out of the required 12 hours. This deficiency was identified during a staff development review conducted on July 5, 2024, as documented in the Alliant Certified Nursing Assistant (CNA) Annual Report. The facility's policy mandates that each nurse aide must receive at least 12 hours of in-service training annually, based on their employment date. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of in-service training hours. The Assistant Director of Nursing (ADON) stated that management was collectively responsible for overseeing in-services and education, but there was no designated person for this task. The ADON was unaware of the non-compliance of CNAs AA and FF with their in-service hours. Similarly, CNA AA was not aware of her shortfall in meeting the in-service education requirement, although she believed she had completed the necessary training. The Director of Nursing expressed an expectation that all CNAs should have their in-service hours completed to prevent potential negative outcomes affecting resident safety.
Failure to Document and Communicate Resolutions to Resident Concerns
Penalty
Summary
The facility failed to ensure proper follow-up and communication regarding resident concerns and recommendations voiced during Resident Council meetings. The review of the facility's policy on Resident Council Meetings indicated that the Activity Director was responsible for facilitating meetings and responding to written requests from the group. However, the facility did not document responses to concerns or recommendations, nor did they provide evidence of thorough investigation or resolution of these issues. This lack of documentation and follow-up was evident in the review of nine Resident Council meeting minutes, which were incomplete and lacked evidence of resolution or satisfaction from the residents. During a Resident Council Meeting, several residents expressed that they had voiced concerns and recommendations but had not received any follow-up or resolutions. Additionally, these residents were unaware of how to file a grievance or who the grievance official was. Interviews with the Activity Director and the Director of Nursing revealed that while concerns were verbally communicated to residents, there was no documentation of resolutions. The Director of Nursing acknowledged the need for documentation and expressed that staff were expected to document resolutions to residents' concerns.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the disrepair of furniture and packaged terminal air conditioners (PTACs) in six out of 56 resident rooms. Specifically, rooms A6-2, B10-1, and C18-2 had dressers with missing drawers and/or knobs, while rooms C13, C15, C18, and C19 had PTACs that leaked water onto the floors. These deficiencies were identified through observations, resident and staff interviews, and a review of the facility's maintenance policy. The policy required routine inspections and immediate correction of any issues, which were not adhered to in this case. During an interview, the Maintenance Director confirmed the observations and acknowledged that the PTACs had been leaking intermittently over the past month due to extreme heat causing increased condensation. Despite the units still functioning, they were not effectively directing the fluid outside, leading to water accumulation on the floors. The Maintenance Director, who worked alone, stated that he cleaned the affected floors every two to three days but had no immediate plans to replace the PTACs. He also mentioned difficulties in conducting routine rounds due to his workload, which contributed to the ongoing issues with the facility's environment.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices, which are crucial for preventing infections and cross-contamination. During an observation on Hall A, Certified Nursing Assistants (CNAs) were seen distributing lunch trays to residents without using hand sanitizer between each delivery. Despite being reminded by a Registered Nurse (RN) to use hand sanitizer, the CNAs continued to neglect this practice. This oversight was observed in multiple rooms, indicating a pattern of non-compliance with the facility's hand hygiene policy. Interviews with the CNAs revealed that they were aware of the requirement to use hand sanitizer but admitted to forgetting to do so. Both CNAs also disclosed that they had not received any handwashing hygiene training since starting their employment at the facility, although they had learned about it during their initial CNA training. The Director of Nursing confirmed that the expectation was for all CNAs to adhere to proper hand hygiene protocols to prevent infection control issues and ensure resident safety.
Failure to Document Change of Condition and Transfer
Penalty
Summary
The facility failed to ensure accurate and timely documentation of a resident's change of condition, as required by its own policy and professional standards. A resident with multiple complex diagnoses, including hypertensive heart and chronic kidney disease, end stage renal disease, dementia, and dependence on dialysis, experienced a significant change in condition characterized by altered mental status, fever, and respiratory distress. The resident was ultimately sent to the emergency department, where diagnoses included hypernatremia, dehydration, acute respiratory failure, sepsis, and pneumonia. Despite these events, there was no documentation in the resident's medical record, nurses' notes, 24-hour report, or SBAR report regarding the change of condition or the events leading to the transfer. Staff interviews confirmed that the nurse and nurse practitioner assessed the resident and arranged for transfer to the hospital, but failed to document the assessment, observations, or rationale for the transfer at the time of the event. The nurse practitioner only wrote an order to send the resident out, without specifying the reason, and the LPN believed she had charted the information but had not. The CNA reported changes in the resident's behavior and communicated this to the nurse, who then took action, but again, no documentation was made at the time. The lack of documentation was only discovered after surveyor inquiry, at which point late entries were made.
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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 Flowery Branch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Lanier | 6.3 mi | — | 0 | 0 |
| New Horizons Limestone | 11 mi | — | 9 | 0 |
| Pruitthealth - Limestone | 11.2 mi | — | 0 | 0 |
| Bell Minor Home, The | 11.4 mi | — | 0 | 0 |
| Willowbrooke Court At Lanier Village Estates | 13.1 mi | — | 3 | 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.