Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Fairburn Heights Of Journey Llc during CMS and state inspections, most recent first.
The facility did not ensure menus were prepared in advance with required details such as serving sizes and diet-specific modifications. After a kitchen fire, staff relied on emergency menus but failed to provide clear documentation or guidance for dietary modifications and portion sizes. Residents received meals that did not match planned menus, and dietary staff lacked instructions for preparing meals according to individual diet orders, placing all residents at risk of nutritional issues and dissatisfaction.
The facility did not maintain required infection control surveillance documentation for the previous year, as confirmed by the DON. A resident was treated for a UTI during this period, but no surveillance records were available to track or monitor infections as outlined in the facility's policy.
Surveyors observed that multiple resident rooms and the main dining room had significant maintenance issues, including damaged drywall, missing or broken tiles, worn furniture, and broken window blinds. Facility staff confirmed awareness of some of these problems, and incomplete repairs were noted during the inspection.
The facility failed to maintain proper food safety and sanitation practices, with unlabeled and expired food items found in storage, and a lack of temperature logs for kitchen equipment. The kitchen environment was unsanitary, with appliances and preparation areas covered in grime. Staff interviews revealed a lack of awareness and adherence to food safety protocols.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate. Three residents received incorrect dosages of medications, as confirmed by an LPN. The DON expects staff to follow physician orders and monitors compliance through audits and observations.
The facility failed to provide meals that were palatable, appetizing, and attractive, affecting 97 residents. Observations showed meals deviated from the planned menu, such as serving a meatless hotdog bun with cheese and chicken noodle soup. The Dietary Manager cited ingredient shortages as the reason for substitutions, while the Registered Dietitian noted that alternate menu choices should be available but had not verified their posting.
The facility failed to properly label and store bath basins, bedpans, and urinals in several rooms, as required by their infection control policy. Observations showed these items were not bagged or labeled, which was confirmed by staff interviews, including a CNA, an LPN, and the DON. This deficiency highlights a lapse in maintaining a sanitary environment to prevent cross-contamination.
The facility failed to assess the ability of four residents to self-administer medications, resulting in medications being left at their bedside without proper authorization. Despite the facility's policy requiring secure storage of medications, observations revealed that medications were left at the bedside for residents with various diagnoses, including lupus, Alzheimer's, and diabetes, without documented assessments for self-administration. The DON confirmed that no residents had self-administration orders, and all medications should be administered under supervision.
The facility failed to honor residents' meal preferences and provide snacks, affecting 108 residents. Residents reported not receiving snacks, cold food, and lack of assistance to the dining room. The Dietary Manager admitted to substituting meals due to menu changes, and the Registered Dietitian noted gaps in providing alternatives and missing menu cards on trays, crucial for dietary communication.
A facility failed to provide a resident and their representative with written bed hold information at the time of hospital transfer or within 24 hours, as required by policy. Despite multiple hospitalizations, there was no evidence of compliance with this requirement. Interviews with staff confirmed the oversight, and the Administrator was unaware of the lapse.
A facility failed to complete a PASARR Level 2 assessment for a resident with schizophrenia and other medical conditions, who was admitted with only a Level 1 assessment from the hospital. Despite the resident's complex needs and use of psychoactive medications, the necessary Level 2 review was not conducted. Interviews revealed that the hospital did not complete the Level 2 assessment in 2021, and the facility did not initiate it upon admission.
A resident with multiple diagnoses was discharged without proper medication reconciliation and documentation. The discharge summary lacked a complete list of medications and necessary signatures, and there was a discrepancy in the resident's code status. Interviews revealed that the resident did not receive all medications, and specific information about their functional level was missing. The LPN admitted to not making a copy of the medication form for the medical record.
The facility failed to ensure a safe environment for three residents, who were found with hazardous items like nail polish remover, isopropyl alcohol, and Hibiclens Antiseptic in their rooms. Despite efforts to declutter and inform residents about prohibited items, these hazards were present. The DON acknowledged the issue of clutter and inappropriate items in resident rooms.
The facility failed to provide effective oxygen therapy for four residents, with issues such as improper storage of equipment, lack of physician orders, and inadequate documentation. One resident with a tracheostomy had essential equipment on the floor, while another received oxygen without an order. Two other residents experienced inconsistencies in oxygen flow rates and documentation, indicating systemic issues in respiratory care management.
A facility failed to document communication between its staff and a dialysis center for a resident with end-stage renal disease. The facility's policy requires ongoing assessment and communication, but several dialysis communication forms were incomplete or missing. Interviews with staff, including an LPN and the DON, confirmed the lack of documentation, which was not addressed until highlighted during a survey.
The facility did not provide meals and snacks according to residents' needs and preferences, affecting 97 out of 112 residents. Despite a policy requiring adjustment of menus to meet individual needs, residents reported not receiving snacks at night. The Dietary Manager admitted to limiting snacks due to concerns about food going missing, and an LPN confirmed that snacks were not offered. The Administrator was unaware of the limited snack provision.
Failure to Prepare and Follow Advance Menus with Diet-Specific Modifications
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and included necessary details such as serving sizes and diet-specific modifications for residents' diet orders. During the survey, the facility was unable to provide complete menu cycles and menu extensions for all diets, and the available documentation did not specify which foods were appropriate for various modified diets, including soft, bite-sized, potassium-restricted, finger food, reduced sodium, no added salt (NAS), and renal diets. Observations revealed that meals served did not always match the planned emergency menus, and handwritten instructions for meal preparation lacked information on portion sizes and diet accommodations. Staff interviews confirmed that, following a kitchen fire, the facility relied on emergency menus but did not consistently provide documentation or guidance for dietary modifications or portion sizes. Residents reported receiving meals that differed from the emergency menu, and dietary staff were observed preparing meals without clear instructions on the amount of food to serve or how to modify meals for specific diets. The Registered Dietician stated that the food service vendor provided menus and recipes for all diets, but these were not fully utilized by the dietary manager during the emergency period. The facility was unable to provide a dietary policy regarding menu preparation and documentation before the survey exit, and the lack of clear, advance menu planning and documentation placed all residents receiving oral meals at risk of nutritional problems and dissatisfaction.
Missing Infection Control Surveillance Documentation
Penalty
Summary
The facility failed to maintain infection control surveillance documentation for the year 2024, as required by its own policy. Review of the facility's Infection Surveillance policy indicated the purpose was to identify and monitor infections to reduce and prevent their spread. However, the only available surveillance documentation was for January through June 2025, with no records for 2024. This deficiency was confirmed during an interview with the DON, who was unable to provide any infection control surveillance records for 2024. Additionally, a resident was treated for a urinary tract infection in December 2024, with supporting documentation in the medical record, but there was no corresponding infection surveillance documentation for that period.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as required by its own policy. Observations conducted across four units revealed multiple deficiencies in 13 resident rooms and the main dining room. Specific issues included gouged and marred drywall, missing or broken tiles, dark discoloration around baseboards, worn laminate on tables, splintered wood on doors, and missing or damaged window blinds. Additional findings included holes in bathroom doors, unsanded and unpainted wall patches, separated drywall seams, missing base molding, and missing drawers in closets. Interviews with the Maintenance Director and Regional Maintenance Director confirmed awareness of some of these issues, with the Maintenance Director acknowledging incomplete repairs, such as unsanded and unpainted drywall patches. The Regional Maintenance Director indicated he was new to the corporation and unaware of the extent of the repair needs. These conditions were directly observed and documented by surveyors during their inspection.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, as observed during a kitchen tour. Several food items in the walk-in cooler and freezer were not labeled or dated, including a container of tea, shredded lettuce, cooked sausage patties, and hot dog buns. Additionally, expired food items such as yogurt and relish were found. The facility also lacked records of daily temperature logs for the freezers, cooler, dishwasher, steam table, and sanitizing solution in the three-compartment sink. This lack of monitoring and documentation could potentially affect 97 of the 112 residents receiving an oral diet. The kitchen environment was found to be unsanitary, with appliances such as the oven, fryer, and convection oven coated in grease and grime. Food preparation areas, countertops, and floors were soiled with food crumbs, dirt, and debris. The ice machine contained a black substance, and the sanitizing sink was surrounded by debris and food particles. The facility's maintenance worker confirmed that the ice machine is cleaned every three months, but there were no logs or manufacturer's cleaning recommendations available. Interviews with the Dietary Manager, Administrator, and kitchen staff revealed a lack of awareness and adherence to food safety protocols. The Dietary Manager confirmed the absence of temperature logs and acknowledged the environmental concerns in the kitchen. The day shift cook was unaware of the requirement to log steam table temperatures, and the Dietary Aid mentioned the absence of a cleaning list. The Administrator recognized the need for a deep clean of the kitchen and acknowledged the potential risk of illness from a dirty ice machine.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency was identified through observation, record review, and staff interviews. Three residents were involved in the medication errors. Resident 44, diagnosed with Alzheimer's Disease and urinary retention, was administered Cranberry 450mg instead of the ordered Cranberry 425mg. Similarly, Resident 46, with Type 2 Diabetes Mellitus and a history of cerebral infarction, received Cranberry 450mg instead of the prescribed Cranberry 425mg. Resident 61, who has a history of cerebral infarction and prediabetes, was given Vitamin D3 125mcg instead of the ordered Vitamin D3 25mcg. The errors were confirmed during an interview with an LPN, who acknowledged the discrepancies between the medications given and the physician's orders. The Director of Nursing (DON) expressed an expectation for staff to adhere to physician orders and indicated that her role includes monitoring staff through audits and observations to ensure compliance. Despite these expectations, the facility's failure to ensure accurate medication administration led to a medication error rate exceeding the acceptable threshold.
Deficiency in Meal Quality and Menu Adherence
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, appetizing, and attractive, affecting 97 of 112 residents on an oral diet. The facility's policy required that menus meet nutritional needs, be prepared in advance, and deviations be documented and approved by a dietitian. However, observations revealed that meals served did not adhere to these standards. For instance, a meal consisting of a meatless hotdog bun with a slice of cheese, chicken noodle soup, and a side of lettuce was deemed unacceptable by the Administrator and Regional Nurse Consultant. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) highlighted issues with menu adherence and food availability. The DM admitted to substituting menu items due to a lack of ingredients, such as using a hotdog bun instead of bread and omitting meat from salads due to a shortage of deli meats. The RD confirmed that alternate menu choices should be available and communicated to residents, but acknowledged that she had not verified if these were posted. The facility's menu was on a 30-day cycle, but frequent changes led to inconsistencies in meal offerings.
Failure to Properly Store and Label Personal Care Items
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment by not labeling and properly storing bath basins, bedpans, and urinals in eight of 49 rooms. Observations revealed that in several rooms on the 300 hall, including rooms 309, 313, 315, 402, 404, 405, 407, and 408, bath basins and bedpans were not labeled or bagged as required by the facility's policy. The policy, dated 2/12/2022, mandates that bedpans and urinals are for single resident use only, should be labeled with the resident's name, and stored in a plastic bag in the resident's bedside cabinet or drawer. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, confirmed that all urinals and bath basins should be bagged and labeled to prevent cross-contamination. The CNA stated that all basins and urinals should be cleaned after each use and changed out every night. Despite these guidelines, the observations indicated a failure to comply with the policy, leading to a deficiency in infection prevention and control within the facility.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of four residents to self-administer medications before leaving medications at their bedside, contrary to the facility's policy on medication storage. The policy mandates that all medications should be stored securely and not left at the bedside unless a clinical assessment deems it appropriate for self-administration. However, observations revealed that medications were left at the bedside for residents R56, R44, R41, and R21 without documented assessments for self-administration. Resident R56, diagnosed with lupus erythematosus, asthma, and other conditions, had several medications, including Trelegy Ellipta Inhaler and Zinc Oxide Ointment, left at the bedside. The Director of Nursing (DON) and the Infection Control Nurse confirmed the presence of these medications, which were not supposed to be there. Similarly, Resident R44, with Alzheimer's Disease and other diagnoses, had Triamcinolone cream at the bedside, which was discontinued earlier in the year. The LPN confirmed the presence of the discontinued medication but was unaware of who left it there. Resident R41, who was cognitively intact, had nasal spray and eye drops at the bedside without an order for self-administration. The LPN confirmed that these medications should not have been left at the bedside. Resident R21, with a BIMS score indicating no cognitive impairment, had diclofenac sodium gel at the bedside without an order for self-administration. The DON confirmed that no residents in the facility had self-administration orders, and all medications should be administered under supervision, ensuring residents take their medications before staff leave the room.
Failure to Honor Resident Meal Preferences and Provide Snacks
Penalty
Summary
The facility failed to honor residents' rights to make choices related to meals and snacks, affecting 108 of 112 residents who can consume meals. The facility's policy stated that the residents' council would be included in menu planning, and alternatives would be provided if a food group was missing from a resident's diet. However, a review of the last six months of resident council meeting minutes revealed complaints about not receiving snacks, cold food, and lack of assistance to the dining room. Observations confirmed that no residents were in the dining room for dinner, and interviews with residents indicated that they were not informed about snack availability and that meal preferences were not honored. Interviews with the Dietary Manager and Registered Dietitian highlighted issues with menu management and communication. The Dietary Manager admitted to substituting meals due to constant menu changes and advised not to rely on the distributed menu. The Registered Dietitian acknowledged gaps in providing alternatives and noted the absence of menu cards on trays, which are crucial for communicating dietary preferences and allergies. These deficiencies in meal service and communication contributed to the failure to support resident choice and self-determination regarding meals and snacks.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide written bed hold information to a resident and their representative at the time of transfer to the hospital or within 24 hours, as required by their policy. This deficiency was identified for one resident, R154, out of three sampled residents. The facility's Bed Hold Policy, dated 2/12/22, mandates that written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed be provided at the time of transfer for hospitalization or therapeutic leave. However, a review of the clinical and financial records revealed no evidence that such information was provided to the resident or their responsible party during multiple hospitalizations. Interviews with facility staff, including the Business Office Manager and an LPN, confirmed that the responsibility for providing the bed hold form lies with the business office manager and licensed nursing staff. The Business Office Manager admitted to not having any electronic or hard copy documentation to show that the bed hold information was provided during the hospitalizations. The Administrator was also unaware that the forms were not being given, despite expecting the staff to provide them. This lack of documentation and communication led to the deficiency being cited by the surveyors.
Failure to Complete PASARR Level 2 Assessment
Penalty
Summary
The facility failed to identify and submit a Preadmission Screening/Resident Review (PASARR) Level 2 review for a resident with a primary diagnosis of serious mental illness, developmental disability, or a related condition. The resident, who has schizophrenia and other medical diagnoses such as hemiplegia and generalized anxiety disorder, was admitted to the facility with only a PASARR Level 1 assessment completed by the hospital. Despite the resident's complex medical and psychiatric needs, including the use of multiple psychoactive medications, the necessary Level 2 assessment was not conducted upon admission. Interviews with facility staff, including the Social Service Director and the administrator, revealed that the PASARR Level 2 was not completed by the hospital in 2021, and the facility did not initiate it upon the resident's admission. The Social Service Director acknowledged that the hospital typically initiates both Levels 1 and 2, but if not, the facility should take responsibility. However, the Level 2 assessment was overlooked, and the Social Service Director was unsure why it was not initiated, as the resident was admitted before her tenure.
Deficiency in Medication Reconciliation and Documentation at Discharge
Penalty
Summary
The facility failed to properly reconcile and document the medications for a resident at the time of discharge, leading to a deficiency in the discharge process. The resident, who had diagnoses including vascular dementia, Parkinson's disease, and type 2 diabetes mellitus, was discharged without a complete and accurate discharge summary. The discharge summary did not list the medications, nor did it include the necessary signatures from the staff and the resident or their family, which are required to confirm that the medications were provided. Additionally, there was a discrepancy in the resident's code status, as the discharge summary incorrectly listed the resident as a full code, while the medical record indicated a Do Not Resuscitate (DNR) status. Interviews with the family and staff revealed that the resident did not receive all prescribed medications upon discharge, and there was a lack of specific information regarding the resident's capabilities and functional level. The Social Service Worker acknowledged the mistake in the code status, and the Director of Nursing confirmed that the discharge summary should have included care instructions, functional level, and medication documentation. The LPN involved admitted to not making a copy of the medication form with the necessary signatures for the resident's medical record, leaving the facility without proof that the medications were given to the resident or their family.
Facility Fails to Prevent Accident Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. Resident 41, who has a history of major depressive disorder, hoarding disorder, and uses a wheelchair, was observed with nail polish remover on their bedside table. The Licensed Practical Nurse (LPN) acknowledged the presence of hazardous items and noted that some rooms have clutter, despite efforts to declutter and inform residents about prohibited items. Resident 9, who is alert and oriented with a history of heart failure and chronic kidney disease, was found with a bottle of isopropyl alcohol on their bedside table. The resident stated they purchased it themselves, and the LPN confirmed its presence, noting that residents and families are informed about restricted items. Resident 24, with hemiplegia and paranoid schizophrenia, had four bottles of Hibiclens Antiseptic on their bedside table. The resident received the bottles from another resident and was educated by a Certified Nursing Assistant (CNA) about not keeping certain chemicals. The Director of Nursing (DON) confirmed awareness of clutter and inappropriate items in residents' rooms.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide effective oxygen therapy for four residents, as observed through various deficiencies in the administration and management of respiratory care. For one resident with a tracheostomy and chronic respiratory failure, essential equipment such as an Ambu bag and suction device were found on the floor, and respiratory tubing was improperly stored, indicating a lack of adherence to infection control measures. This resident's care plan included specific orders for tracheostomy care and oxygen therapy, yet the observed conditions did not align with these requirements. Another resident, who was dependent on supplemental oxygen due to chronic respiratory failure and other conditions, was observed receiving oxygen therapy without a physician's order. Despite being on hospice care and having a care plan that highlighted the need for oxygen, the resident's oxygen therapy was not documented in the Medication Administration Record (MAR), and staff interviews confirmed the absence of an official order. This lack of documentation and oversight suggests a failure in maintaining proper records and ensuring physician-directed care. For two additional residents, discrepancies were noted in the administration of oxygen therapy. One resident had a PRN order for oxygen, but observations revealed inconsistencies in the oxygen flow rate and improper storage of equipment, such as dirty filters and unbagged tubing. Another resident was receiving continuous oxygen therapy without a physician's order or documentation in the MAR, and the care plan lacked any mention of oxygen therapy. Interviews with nursing staff and the Director of Nursing confirmed these oversights, highlighting a systemic issue in the facility's management of respiratory care.
Failure to Document Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication and documentation between its staff and the dialysis center for a resident receiving dialysis. The facility's policy on hemodialysis requires ongoing assessment and communication with the dialysis center, including monitoring the resident's condition before, during, and after dialysis treatments. However, the review of the resident's medical records revealed missing dialysis communication forms for several dates, indicating a lack of documentation of vital signs, assessment of the dialysis access site, and other necessary information. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the forms were incomplete and not properly uploaded into the electronic medical records system. The resident in question had a history of hypertensive chronic kidney disease, end-stage renal disease, legal blindness, and cerebellar stroke syndrome. Despite physician orders for dialysis on specific days, the facility failed to document the necessary information on the dialysis communication forms. The DON acknowledged that the forms were not being completed as required by policy and was unaware of the issue until it was highlighted during the survey. The lack of documentation and communication could potentially impact the resident's care and treatment, as the facility did not ensure that the necessary information was communicated to and from the dialysis center.
Failure to Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were served according to the residents' needs, preferences, and requests, as required by their policy. The policy, dated April 2024, stated that menus and available snacks should be adjusted to meet individual caloric and nutrient-intake needs. However, during a Resident Council meeting, residents expressed concerns about not receiving snacks at night. Observations revealed that the pantry contained only a limited selection of snacks, such as chocolate sandwich cookies, graham crackers, and chocolate wafer bars. The Dietary Manager admitted to providing only a limited number of snacks due to concerns about food going missing at night and confirmed the lack of ingredients to prepare sandwiches. Interviews with staff further highlighted the deficiency. The Administrator was aware of the issue of food going missing but was unaware of the limited snack provision. An LPN stated that snacks were not offered to residents, and only some received a snack bag. This deficiency affected 97 out of 112 residents, as they were not provided with nourishing alternative snacks at non-traditional times or outside of scheduled mealtimes, contrary to the facility's policy and the residents' expressed needs.
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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 Fairburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian City Rehabilitation Center | 3.6 mi | — | 2 | 0 |
| Pruitthealth - Fairburn | 5.8 mi | — | 0 | 0 |
| Fountainview Ctr For Alzheimer | 9.4 mi | — | 0 | 0 |
| Healthcare At College Park, Llc | 9.9 mi | — | 0 | 0 |
| Fayetteville Center For Nursing & Healing Llc | 10.1 mi | — | 7 | 0 |
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