Fairburn, GA

Fairburn Heights Of Journey LLC

1-star overall rating with 1-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

178 West Campbellton Street, Fairburn, GA

(770) 964-1320

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

105

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Journey Healthcare

Operator or chain grouping

Approved since

1982-05-07

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

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

0.20

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

2.01

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.09

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.08

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.76

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.11

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

2.45

CMS adjusted total nurse staffing hours

Case-mix index

1.72

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

13,176

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

7.70

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.06% · Performance 21.99% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.31

Baseline 9.37% · Performance 8.14% · Measure score 2.31 · Achievement 0 · Improvement 2.31

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

Baseline 3.26 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.68%	10.72% 1 pts worse	No Different than the National Rate · Eligible stays 42 · Observed rate 19.05% · Lower 95% interval 7.51%
Discharge to community	34.94%	50.57% 15.6 pts worse	Worse than the National Rate · Eligible stays 33 · Observed rate 15.15% · Lower 95% interval 21.05%
Medicare spending per beneficiary	1.48	1.02 0.5 pts worse
Drug regimen review with follow-up	97.83%	95.27% 2.6 pts better	Numerator 45 · Denominator 46
Falls with major injury	2.17%	0.77% 1.4 pts worse	Numerator 1 · Denominator 46
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	8.7%	2.29% 6.4 pts worse	Numerator 4 · Denominator 46 · Adjusted rate 7.1%
Healthcare-associated infections requiring hospitalization	8.14%	7.12% 1 pts worse	No Different than the National Rate · Eligible stays 33 · Observed rate 15.15% · Lower 95% interval 4.7%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 73
Staff flu vaccination coverage	20.93%	42% 21.1 pts worse	Numerator 18 · Denominator 86
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to provider	90.32%	95.95% 5.6 pts worse	Numerator 28 · Denominator 31
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	2.2 About the same	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	2.0 0.1 pts better	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	49.5%	91.2% 41.7 pts worse	93.4% 43.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 41.4% · Q3 42.7% · Q4 66.7% · 4Q avg 49.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	50.5%	95.0% 44.5 pts worse	95.5% 45 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 50.5%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.2% 2.4 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	38.3%	9.6% 28.7 pts worse	11.4% 26.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 45.0% · Q3 54.3% · Q4 38.1% · 4Q avg 38.3%
Percentage of long-stay residents who lose too much weight	2.4%	5.9% 3.5 pts better	5.4% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 4.1% · Q4 1.3% · 4Q avg 2.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.6%	20.7% 10.1 pts better	19.6% 9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 8.1% · Q3 12.2% · Q4 9.8% · 4Q avg 10.6%
Percentage of long-stay residents who received an antipsychotic medication	8.5%	21.4% 12.9 pts better	16.7% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.7% · Q3 12.2% · Q4 6.0% · 4Q avg 8.5% · 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	28.7%	17.9% 10.8 pts worse	16.3% 12.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 21.7% · Q3 36.8% · Q4 54.7% · 4Q avg 28.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.8%	16.2% 15.6 pts worse	14.9% 16.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 24.6% · Q3 40.6% · Q4 41.9% · 4Q avg 31.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.7%	1.1% 0.4 pts better	1.0% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.5% 2.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.4%	16.1% 7.3 pts worse	19.8% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 16.8% · Q3 21.6% · Q4 35.2% · 4Q avg 23.4%
Percentage of long-stay residents with pressure ulcers	6.3%	6.2% 0.1 pts worse	5.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.6% · Q3 4.8% · Q4 3.9% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	25.0%	80.4% 55.4 pts worse	81.7% 56.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 8.0% · Q4 59.7% · 4Q avg 25.0%
Percentage of short-stay residents who had an outpatient emergency department visit	11.1%	12.2% 1.1 pts better	12.0% 0.9 pts better	Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 14.0% · Expected 14.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	2.2% 2.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	8.1%	78.2% 70.1 pts worse	79.7% 71.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 8.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.4%	24.2% 1.2 pts worse	23.9% 1.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 32.6% · Expected 30.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-05 · Fire 2024-08-05

16 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-12-15 · Fire 2022-12-15

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-08-08 · Fire 2019-08-08

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-08-05

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-08-05

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-08-05

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-09-19

D · Potential for more than minimal harm 2019-08-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-09-22

D · Potential for more than minimal harm 2019-08-08

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-09-22

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-06-19

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-07-23

F · Potential for more than minimal harm 2025-06-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-23

E · Potential for more than minimal harm 2025-06-19

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 2025-07-23

F · Potential for more than minimal harm 2024-08-05

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 2024-09-19

E · Potential for more than minimal harm 2024-08-05

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-08-05

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-09-19

E · Potential for more than minimal harm 2024-08-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-09-19

D · Potential for more than minimal harm 2024-08-05

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2024-09-19

G · Actual harm 2022-12-15

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-02-13

F · Potential for more than minimal harm 2022-12-15

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 2023-02-13

D · Potential for more than minimal harm 2022-12-15

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 2023-02-13

D · Potential for more than minimal harm 2022-12-15

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 2023-02-13

D · Potential for more than minimal harm 2022-12-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-02-13

D · Potential for more than minimal harm 2019-08-08

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2019-09-22

D · Potential for more than minimal harm 2019-08-08

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 2019-09-22

D · Potential for more than minimal harm 2019-08-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-09-22

D · Potential for more than minimal harm 2019-08-08

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 2019-09-22

Penalties and ownership