Cycle 1
Health 2024-08-28 · Fire 2024-08-28
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Flowery Branch, GA
Crossroads Of Flowery Branch Of Journey LLC, The
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4595 Cantrell Road, Flowery Branch, GA
(770) 967-2070
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Journey Healthcare
Operator or chain grouping
Approved since
1984-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.22
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.92
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
2.20
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,432
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.46% · Performance 22.48% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.59
Baseline 9.41% · Performance 8.49% · Measure score 1.59 · Achievement 0 · Improvement 1.59
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.21 hours · Performance 2.88 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 8.82% · Lower 95% interval 6.32% |
| Discharge to community | 41.45% |
50.57%
9.1 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 28.17% · Lower 95% interval 30.21% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 90 · Denominator 90 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 90 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 14 · Denominator 42 |
| Discharge mobility score | 26.19% |
50.94%
24.7 pts worse
|
Numerator 11 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 5 · Denominator 90 · Adjusted rate 4.57% |
| Healthcare-associated infections requiring hospitalization | 8.49% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 13.33% · Lower 95% interval 5.54% |
| Staff COVID-19 vaccination coverage | 48.68% |
8.2%
40.5 pts better
|
Numerator 37 · Denominator 76 |
| Staff flu vaccination coverage | 21.59% |
42%
20.4 pts worse
|
Numerator 19 · Denominator 88 |
| Discharge function score | 28.57% |
56.45%
27.9 pts worse
|
Numerator 12 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.33% |
25.2%
16.9 pts worse
|
Numerator 3 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
91.2%
0.3 pts better
|
93.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 66.2% · 4Q avg 91.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.4% |
95.0%
1.6 pts worse
|
95.5%
2.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.2%
0.2 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.4% · Q3 2.5% · Q4 3.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.2% |
9.6%
21.6 pts worse
|
11.4%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 14.5% · Q3 73.2% · Q4 40.6% · 4Q avg 31.2% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.9%
2.6 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 10.7% · Q3 5.7% · Q4 2.7% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
20.7%
5.7 pts worse
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 27.3% · Q3 26.8% · Q4 23.0% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
21.4%
4 pts better
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 17.2% · Q3 18.9% · Q4 14.3% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.8% |
17.9%
8.9 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 21.6% · Q3 27.3% · Q4 33.9% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
16.2%
6.3 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.3% · Q3 28.6% · Q4 35.7% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.1%
1.7 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.5% · Q3 1.4% · Q4 1.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.5%
2.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
16.1%
4.5 pts worse
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 21.0% · Q3 14.6% · Q4 31.9% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
6.2%
4.7 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 16.5% · Q3 6.8% · Q4 6.9% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
80.4%
7.8 pts better
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 62.7% · 4Q avg 88.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
12.2%
6.5 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 21.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.2%
1.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 17.0% |
78.2%
61.2 pts worse
|
79.7%
62.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 17.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
24.2%
1 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 30.8% · Expected 29.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-06 · Fire 2022-11-06
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2021-06-04 · Fire 2021-06-04
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-10
D · Potential for more than minimal harm
2022-11-06
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-21
D · Potential for more than minimal harm
2021-06-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-07-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-30
E · Potential for more than minimal harm
2025-07-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-30
F · Potential for more than minimal harm
2024-08-28
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-08-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-07-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-05
F · Potential for more than minimal harm
2022-11-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-12-21
E · Potential for more than minimal harm
2022-11-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-12-21
E · Potential for more than minimal harm
2022-11-06
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-12-21
E · Potential for more than minimal harm
2022-11-06
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-12-21
D · Potential for more than minimal harm
2021-06-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-06-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-07-12
Penalties and ownership
What sits behind the stars
Ownership
Bilbo, Richard
Operational/Managerial Control · Individual
Conrad, Cameron
Operational/Managerial Control · Individual
Frinks, Terence
Operational/Managerial Control · Individual
Johnson, Jennifer
Operational/Managerial Control · Individual
Jones, Antonio
Operational/Managerial Control · Individual
Journey Ox Ga Management LLC
Operational/Managerial Control · Organization
Looney, Micah
Operational/Managerial Control · Individual
Mcguinness, Bernard
Operational/Managerial Control · Individual
Ng, Scott
Operational/Managerial Control · Individual
Omara, Jody
Operational/Managerial Control · Individual
Parker, Yolanda
Operational/Managerial Control · Individual
Sillings, Nikki
Operational/Managerial Control · Individual
Trammell, Matthew
Operational/Managerial Control · Individual
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#3
PruittHealth - Limestone
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4-star overall rating with 3-star inspections with 5 recent health deficiencies
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