Citations in Georgia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Georgia.
Statistics for Georgia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Georgia
Surveyors found that the facility lacked a Legionella water management program, with leadership and maintenance staff unaware of any such program despite a prior isolated Legionella test. A nurse administering medication via a G-tube to a resident on Enhanced Barrier Precautions wore gloves but not a gown, contrary to facility policy, and reported not knowing a gown was required. An LPN performing wound care for a resident with a Stage IV sacral pressure ulcer and multiple comorbidities failed to disinfect the treatment cart, bedside table, or bed surface before placing clean supplies, used the same gloves to cleanse the wound and handle clean dressings, and only washed a reusable wound cleanser bottle with soap and water. Additionally, a resident’s oxygen concentrator was repeatedly observed with a filter covered in thick gray debris, while staff interviews showed confusion about who was responsible for cleaning oxygen equipment and how often tubing and filters should be maintained.
The facility failed to maintain clean PTAC filters in multiple resident rooms across all sampled halls. Surveyors observed that PTAC units in several rooms had two filters each that were covered with a grey, fuzzy substance thick enough to make the filters opaque, and re-observations on a later day showed the buildup remained. A walk-through with the Maintenance Director confirmed that PTAC units on all halls required cleaning, indicating that the issue was building-wide and affected the environment for residents, staff, and visitors.
A resident with dementia and moderate cognitive impairment, who required supervision for eating and mobility, was asked by an LPN to leave the dining room and return to her room after she had finished her meal so that other residents who had not yet eaten could do so without it appearing they had not been fed. When the resident returned to the dining room a short time later, the LPN again redirected her out, citing that others were still eating. Facility policies stated that residents have the right to exercise their rights without interference and to have unrestricted access to common areas unless there is a safety risk, and leadership later acknowledged that asking the resident to leave a preferred common area was a dignity and rights issue.
Surveyors found that the facility failed to control environmental hazards and prevent elopement. A cognitively intact resident with a seizure disorder and multiple cardiac and psychotropic meds kept and self-administered unsecured OTC cold and flu medication in his room without a physician order. Two other residents, one severely cognitively impaired with vascular dementia and visual loss and another with hemiplegia and contractures, had unsecured shaving razors accessible on top of bedside furniture, contrary to the DON’s expectation that razors be stored in enclosed bags out of reach. In addition, a resident with dementia, depression, and documented wandering and exit-seeking behaviors, care planned as at moderate to high elopement risk and ordered to have a wanderguard on a secure unit, was able to leave the building during a power disruption related to sprinkler system work; staff later observed her crossing multiple lanes of traffic after an exit door had been found open.
Surveyors identified multiple medication administration errors and policy noncompliance, including an LPN giving a multivitamin without minerals instead of an ordered vitamin-mineral tablet, failure to apply a prescribed Lidoderm patch when it was unavailable and inaccurate MAR documentation indicating it was given, administration of Metoprolol despite the resident’s SBP being below the ordered hold parameter, and an RN administering long-acting insulin outside the ordered morning time without priming the insulin pen or holding it in place after injection. Staff interviews revealed lack of adherence to MAR verification requirements and unfamiliarity with proper insulin pen technique.
Surveyors found that medications were not properly stored or managed, including expired floor-stock Dextrose injections discovered in a medication room and multiple insulin pens on a medication cart that were either expired, missing required open/expiration dates, or labeled with an incorrect 7-day expiration instead of the manufacturer-recommended 28 days. An RN acknowledged unawareness of expired Dextrose stored in a box under the counter, and an LPN confirmed that multiple nurses use the carts and that the insulin pens had not been labeled according to expectations. The DON reported that nurses are required to verify the MAR before administration, unit managers must routinely check carts and medication rooms, and all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, noting that expired medications may be harmful and have unknown side effects.
The facility failed to implement DPH-recommended diagnostic testing during a GI outbreak that affected all units, involving 33 residents and 13 staff with nausea, vomiting, diarrhea, and some fevers. Although DPH advised testing individuals with diarrhea and the facility had a standing order to document and fax such recommendations to the physician, the physician was not informed and therefore did not order stool samples, while the NP, though aware of the recommendation, declined testing for residents under her care. The DON was unaware that the Infection Preventionist had reported a diagnosis instead of symptoms to DPH and acknowledged the physician should have been notified of the recommendation, and the Administrator reported not knowing the specific virus involved and confirmed the DPH report should have focused on symptoms and prescribed treatment.
A resident with severe cognitive impairment and multiple chronic conditions was found to have been restrained in a wheelchair with a gait belt, contrary to facility policy prohibiting restraints for discipline or staff convenience. Progress notes and staff interviews revealed that the resident, who had been repeatedly getting out of bed, was placed in a wheelchair, and a gait belt was wrapped around the upper body and the back of the wheelchair, effectively tying the resident in place. A CNA discovered the restraint while preparing a Hoyer lift transfer, removed the gait belt, and assisted the resident to bed. The incident was documented in the medical record, and the resident’s responsible party was notified.
A resident with multiple serious conditions, including post-stroke hemiplegia and chronic systolic CHF, had conflicting advance directive documentation in the record. Earlier documentation and care plans reflected DNR status, but a later POLST and advance directive signed by the resident and a physician changed the status to Full Code. Despite this, the EMR orders and header continued to display DNR due to staff error in discontinuing the wrong directive and failing to update the system. Staff interviews confirmed that they rely on the EMR banner and orders to determine code status, meaning they would see DNR when the resident’s current directive was Full Code.
A cognitively impaired resident with vascular dementia, anxiety, and major depressive disorder, care planned for poor decision-making and need for monitoring, was left vulnerable when an EVS housekeeper entered the resident’s room, closed the door, and remained inside for several minutes. Video footage showed the housekeeper entering the room after previously entering another room without knocking. A CNA later entered and reported seeing the housekeeper standing with his pants down while the resident lay in bed with his penis in her mouth, after which he reacted and fled to the bathroom. In a subsequent police-recorded interview, the resident stated that her mind was gone and that she did not enjoy the encounter, indicating the housekeeper did. These events show the facility failed to protect the resident from sexual abuse by staff.
Infection Control Failures in Water Management, EBP, Wound Care, and Respiratory Equipment
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control program, including the absence of a Legionella water management program. Review of the Infection Prevention and Control Program policy revealed no language addressing Legionella testing or prevention. When surveyors requested the water management program, the Maintenance Director produced an empty clipboard and stated he had never heard of a water management program. The DON and the Administrator both reported they were unaware that there was no water infection prevention program in place, although the Administrator produced a single Legionella test report from the prior year. Surveyors also identified failures to follow Enhanced Barrier Precautions (EBP) and aseptic wound care technique. A nurse administering alprazolam via a G-tube to a resident on EBP wore gloves but did not don a gown for this high-contact care involving an indwelling medical device, despite facility policy requiring gown and gloves for such activities. The nurse later acknowledged she should have worn a gown and stated she was not aware that PPE, including a gown, was required when administering medications via the G-tube, even though EBP signage was posted on the resident’s door. In a separate observation, the LPN responsible for wound, skin, and ostomy care performed dressing care for a resident with a Stage IV sacral pressure wound without disinfecting the treatment cart, bedside table, or bed surface before placing clean supplies. The LPN used the same pair of gloves to cleanse the wound and then handle clean supplies and apply CollaSorb powder and calcium alginate dressing, and washed a reusable wound cleanser bottle with soap and water while gloved before returning it to the cart. The resident with the Stage IV sacral wound had significant comorbidities, including type 1 diabetes mellitus with neuropathy and circulatory complications, chronic kidney disease stage 3A, cerebrovascular disease, and polyneuropathy. The care plan for this resident included goals and interventions focused on wound healing, infection prevention, and monitoring for signs of infection, with physician orders specifying cleansing with wound cleanser or normal saline, application of collagen and calcium alginate, skin prep to the periwound, and dressing changes three times weekly and as needed. During interview, the LPN reported no observed breaches in infection control, believed her actions were appropriate, and stated that hand hygiene was only required twice during the procedure, and that washing the wound cleanser bottle with soap and water was sufficient, which contrasted with the DON’s stated expectations for disinfecting equipment and performing hand hygiene. Additional observations showed an oxygen concentrator in use by another resident with a filter covered in fuzzy, thick, dry gray particles on multiple days, while staff interviews revealed uncertainty among CNAs, nurses, the unit manager, and the DON about who was responsible for cleaning oxygen machine filters, how often tubing was changed, and how often filters should be cleaned, despite the DON stating that the RT was supposed to follow up on all residents on oxygen.
Failure to Maintain Clean PTAC Filters Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not cleaning the Packaged Terminal Air Conditioner (PTAC) filters in multiple resident rooms across all sampled halls. On 01/27/2026, surveyors observed that PTAC units in rooms D16, D12, D15, E52, and E41 had two filters each, and the filters were covered with a grey, fuzzy substance approximately 1/8 inch thick in some cases, making the filters opaque. A re-observation of room D15 later that afternoon showed the filters still had the same grey, fuzzy buildup. On 01/28/2026, follow-up observations revealed that the PTAC filters in rooms D16, D12, D15, and E41 continued to have the grey, fuzzy substance that rendered the filters opaque. During a walk-through with the Maintenance Director on the same day, it was identified that all PTAC units in the building, including those on B, C, E, A, and D halls, required cleaning. This deficient practice was cited as a failure to provide a safe, easy-to-use, clean, and comfortable environment for residents, staff, and the public, with the report stating that it had the potential to cause respiratory irritation and exacerbation of conditions in residents with chronic obstructive pulmonary disease and other related lung diseases.
Resident Rights and Dignity Not Honored in Dining Room Access
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices and have unrestricted access to common areas, as outlined in its own Resident Rights policies. The facility’s policies, revised in November 2025, state that residents have the right to be treated with respect and dignity, to exercise their rights without interference, and to have unrestricted access to common areas open to the public unless there is a safety risk. The resident involved, identified as R38, had diagnoses including unspecified dementia with moderate cognitive impairment (BIMS score of 8), anxiety, and repeated falls, and required supervision/touching assistance for eating and mobility. Her care plan identified a behavior problem related to going in and out of other residents’ rooms and removing items, with interventions focused on providing appropriate activities, anticipating needs, and monitoring behaviors and potential causes. On the observed date and time, during lunch in the E Hall dining room, an LPN entered the dining room and announced that residents who had already eaten should go to their rooms so that residents who had not yet eaten could do so and it would not appear that those without trays had not been fed. The LPN specifically told R38, who had already eaten, to leave the dining room so that other residents who had not been fed could eat, and R38 wheeled herself out of the dining room. When R38 returned a few minutes later, the LPN again redirected her out of the dining room, stating that the other residents had not yet finished eating. In an interview, the LPN acknowledged asking residents to leave so it did not look like a dignity issue to families and stated she did not feel it infringed on R38’s rights because the resident “didn’t know” due to dementia and memory issues. The DON later stated it was not acceptable to ask residents to leave a preferred space if that was where they wanted to be and that it was a dignity issue and a rights issue for the resident to be asked to go to her room.
Unsecured OTC Medications, Razors, and Failed Elopement Prevention
Penalty
Summary
The deficiency involves the facility’s failure to keep resident rooms free of accessible accident hazards, specifically unsecured over-the-counter (OTC) medications and shaving razors, and failure to adequately secure and monitor exit doors to prevent an elopement. Facility policy F 689 Accidents requires the environment to be as free from accident hazards as possible and calls for ongoing identification of safety risks, QAA/Safety Committee evaluation of hazards, and implementation and monitoring of interventions. The facility’s wandering/unsafe resident policy requires assessment of at-risk individuals, care plan identification of elopement risk, and inclusion of safety interventions. Despite these policies, surveyors observed multiple instances where hazardous items were accessible in resident rooms and where an at-risk resident was able to leave the building unsupervised. One cognitively intact resident with a seizure disorder, schizophrenia, depression, hypertension, and multiple prescribed medications, including anticoagulant and antiepileptic drugs, was found with two bottles of brand-name cold and flu OTC medication on a shelf at the foot of the bed. One bottle was nearly empty and the other half full, indicating prior use. The medications were unsecured and accessible. The resident reported he had purchased the cough medication himself because he felt the amount provided by the facility was not enough and that he took more of the medication because it worked for his cough. A nursing progress note documented that the resident had the cold medication in his room without a physician’s order and had been taking it at his discretion. The DON later stated that OTC medications should not be accessible to residents, except for an inhaler after assessment, due to concerns that residents, wandering residents, or visiting children might take them or that residents might not know how much to take. Two other residents were found with unsecured shaving razors accessible in their rooms. One resident with severe cognitive impairment, vascular dementia, visual loss in both eyes, difficulty walking, muscle weakness, and dependence on staff for wheelchair mobility had several shaving razors in a clear plastic bag on top of the bedside nightstand. The resident stated the razors belonged to him and that he used them, which is why they were present in the room. Another cognitively intact resident with hemiplegia/hemiparesis, contractures, difficulty walking, and need for assistance with personal care had a shaving razor in a cup on top of a dresser adjacent to the bed. This resident reported shaving independently and also shaving his head. The Unit Manager RN confirmed the presence of razors in both rooms and acknowledged they were a safety concern. The DON stated that residents are assessed on admission for ability to use razors and may keep them only if they are in an enclosed bag, out of reach, inside the nightstand, and care planned for their use, conditions that were not met in these observations. The facility also failed to prevent an elopement for a resident with dementia, depression, restless legs syndrome, and recent wandering and exit-seeking behaviors. A behavioral health evaluation documented wandering behaviors and difficulty redirecting the resident, and a care plan conference noted that the resident had been having exit-seeking behaviors requiring frequent redirection. The resident’s care plan identified a behavior problem related to walking the halls with belongings and refusing to return them to her room, and a subsequent care plan problem documented that she was at moderate to high risk for elopement, currently wandered, packed belongings to go home, and stayed near exit doors. Interventions included lodging on a secure unit and use of a wanderguard on the right wrist, with orders to check placement each shift and document its location. Despite being on a locked unit with exits that were supposed to be locked, staff interviews revealed that during an electrical outage associated with sprinkler system servicing, the resident was able to leave the building. An LPN reported that the resident went out the front exit during the outage. A CNA described walking by an exit door, feeling a breeze, and noticing the door was open. He checked a gate outside that door but could not open it and suspected the resident had used an alternate door near the activities area with a ramp. He then went to notify the RN and ran to the street, where he saw the resident crossing five lanes of traffic and continuing to walk several houses down from a visible house near the facility. The CNA stayed with the resident until assistance arrived. He stated that the resident exit sought daily, constantly went to the doors shaking them, and always had her bags packed and at the door. The DON and Administrator confirmed that sprinkler system testing had affected the power and that doors had been open while staff were conducting fire watch, during which time the resident was able to elope.
Medication Administration Errors and Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate medication administration in accordance with physician orders and facility policy, resulting in a 16% medication error rate during the survey’s 25 observed opportunities. One resident had an order for a Multiple Vitamins-Minerals tablet once daily for supplementation, but the LPN administered a One-Daily Multivitamin without minerals, which did not match the ordered medication. Facility policies required verification of the right medication, dose, time, and route against the MAR and checking labels multiple times, but these steps were not followed in this instance. Another resident had an order for a Lidoderm (Lidocaine) 5% patch to be applied to the lower back every 12 hours and removed per schedule, but the nurse did not administer the patch because it was not available on the cart, in the medication room, or in the automated medication system. The physician was not notified of the missed dose, and the MAR reflected that the patch had been administered on multiple occasions despite the lack of available patches. The unit manager was initially unaware of the unavailability, and the resident later reported not receiving the patch the previous day or on the day of interview, instead requesting Tylenol for pain. A third resident had an order for Metoprolol Tartrate 25 mg by mouth once daily for HTN, with instructions to hold the dose if HR was 50 or lower or if SBP was below 120. At the time of administration, the resident’s BP was 109/54 mmHg and HR was 56, yet the LPN administered the medication outside the ordered BP parameter, stating she only considered the HR and not the BP. A fourth resident had an order for Insulin Glargine (Lantus) 26 units subcutaneously every morning and at bedtime for diabetes, but the RN administered the morning dose at 1:11 PM instead of in the morning, did not prime the insulin pen, and did not hold the pen in place after injection as required by manufacturer guidance and facility expectations. The RN reported being unfamiliar with the procedures for priming and holding the insulin pen and had not received training on the facility’s insulin pen administration policy.
Expired and Improperly Labeled Medications and Insulin Pens
Penalty
Summary
Surveyors identified a failure to properly store and manage medications, including expired and undated drugs, in a medication room and on a medication cart. Review of the facility’s policy "Storage of Medications F761" stated that discontinued, outdated, or deteriorated drugs or biologicals must not be used and must be returned to the pharmacy or destroyed. During an observation of the A/B/E-Hall medication room on the second floor with a unit manager RN, five floor-stock 50% Dextrose injection 25 g/50 mL units were found in a box under the counter with an expiration date of 07/2025. The RN confirmed the medications were expired and stated she was not aware they were in that box. During a separate observation of the B-Hall medication cart with an LPN, surveyors found multiple issues with insulin pens. One insulin Aspart pen had an open date of 1/1/2026 and an expiration date of 1/31/2026, indicating it had been in use for more than 28 days and was expired as of 1/28/2026. One Lantus Solostar insulin pen was open and in current use with no documented open date or expiration date. One insulin Lispro (Humalog) KwikPen was labeled with an open date of 1/28/2026 and an expiration date of 2/5/2026, reflecting a 7-day expiration instead of the manufacturer-recommended 28 days after opening. The LPN confirmed the labeling issues, stated that multiple nurses use the carts and that she did not open or label those pens, and acknowledged that insulin removed from refrigeration should be dated and assigned a 28-day expiration. The DON later stated that nurses are required to verify the MAR three times before administration, unit managers are responsible for weekly cart checks and daily medication room checks, and that all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, and that use of expired medications may be harmful with unknown potential side effects.
Failure to Implement DPH-Recommended Diagnostic Testing During GI Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow Department of Public Health (DPH) recommendations for diagnostic testing during a gastrointestinal (GI) outbreak affecting all six units. The facility’s infection surveillance policy states that the Infection Preventionist and the attending physician will determine if laboratory tests are indicated. A GI outbreak with symptoms of nausea, vomiting, diarrhea, and some fevers occurred among 33 residents and 13 staff, and DPH was contacted for guidance regarding a possible Norovirus outbreak. DPH later recommended that individuals experiencing diarrhea receive testing and inquired whether the facility had a contract with a commercial lab. However, the physician was not informed of this recommendation and therefore did not order stool samples, stating he routinely does not order stool cultures and was unaware of DPH’s guidance. The NP reported she was aware of the recommendation to test for Norovirus but declined testing for residents under her care, stating the treatment plan would be the same and that residents were already receiving treatment. Interviews revealed multiple communication and implementation failures related to the DPH recommendations. The Infection Preventionist/Quality Assurance LPN confirmed the scope of the outbreak, but the DON stated she was not aware that the Infection Preventionist had listed a diagnosis for DPH instead of only symptoms and confirmed that the physician should have been informed of the DPH recommendation. The physician standing order required that any treatment or testing recommendations from the health department be documented, faxed to the physician, and a copy retained at the facility, but this process was not followed. The NP indicated that by the time the DPH recommendation was communicated, there were no longer residents with active GI symptoms under her care. The Administrator stated she did not know the type of virus present and confirmed that the report to DPH should have described the symptoms and treatment prescribed according to the physician’s orders. These actions and inactions resulted in the facility not implementing DPH’s recommended diagnostic testing for symptomatic residents during the outbreak.
Improper Use of Gait Belt as Physical Restraint in Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints, as required by its policy titled "Restraints/Bed Rails" and regulatory standards. The facility’s policy states that residents have the right to be free from any physical restraints imposed for discipline or staff convenience and not required to treat medical symptoms. The resident involved, identified as R6, had multiple diagnoses including type 2 diabetes mellitus, mood disorder, hypertension, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. A quarterly MDS with an ARD of 11/19/2025 documented a BIMS score of 1, indicating severe cognitive impairment. The care plan noted cognitive decline and emphasized respecting the resident’s right to make decisions. Progress notes from 11/10/2025 through 1/11/2026 documented a situation in which staff used a gait belt to restrain R6 to his wheelchair. During an interview, an LPN reported receiving a call from a CNA who informed her that the resident was tied to a wheelchair with a gait belt. Another CNA described that the resident had been getting out of bed despite bedside mats and was placed in a wheelchair; when preparing to use a Hoyer lift to transfer the resident to bed, the CNA observed a gait belt wrapped around the resident’s upper body and the outer back of the wheelchair, effectively restraining the resident. The CNA immediately removed the gait belt and transferred the resident to bed. The report notes that the responsible party was notified and that the resident did not sustain injuries. The DON later stated that a CNA was terminated for substantiated abuse, and the Administrator stated that her expectation is that no residents be restrained.
Failure to Update EMR to Reflect Resident’s Current Advance Directive and Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s current advance directive and code status were accurately and consistently documented in the electronic medical record (EMR). The facility’s policy on Advance Directives states that a resident’s choice about advance directives will be respected, including Do Not Resuscitate (DNR) orders. One resident was admitted and re-admitted with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, acute chronic systolic congestive heart failure, and hypertensive heart and chronic kidney disease with heart failure. The admission record documented the resident’s code status as DNR, and the care plan reflected that the resident/family desired DNR status, with interventions to follow facility protocol for DNR and not resuscitate the resident per resident/family request. The Annual MDS showed a BIMS score of 10, indicating moderately impaired cognition. Subsequently, physician orders and POLST forms in the record showed conflicting code statuses over time. There was a physician order for Full Code that was later discontinued, followed by an order for DNR, and the EMR header documented the code status as DNR. One POLST documented DNR/Allow Natural Death, while a later POLST documented Full Code/Attempt Resuscitation and was signed by a physician and the resident. The Social Services Assistant confirmed that the later Full Code advance directive should have rendered the prior DNR directive null and void and acknowledged that the EMR had not been updated to reflect the current Full Code status. The Interim DON confirmed that the EMR still showed a DNR order and DNR status in the header despite a current Full Code advance directive on file, and stated she had inadvertently discontinued the wrong advance directive and entered the DNR order in error. The Unit Manager confirmed that staff rely on the EMR orders and banner/header to determine a resident’s advance directive and that, for this resident, staff would see DNR in both locations while the current status was actually Full Code.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Housekeeping Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by an Environmental Services (EVS) housekeeper, in violation of its abuse, neglect, and exploitation policy, which prohibits sexual abuse defined as non-consensual sexual contact of any type with a resident. The resident involved had diagnoses including anxiety, major depressive disorder, and vascular dementia, and her most recent MDS assessments showed moderately impaired cognition with poor decision-making skills, need for cueing and reminders, and cognitive loss/dementia as an area of concern. Her care plan identified poor decision-making and required staff monitoring and redirection as needed. On the day of the incident, facility camera footage showed the resident leaving her room briefly and then returning and closing the door, with no further exit observed. Later that afternoon, the EVS housekeeper entered another resident’s room without knocking, then exited and shortly thereafter knocked on the involved resident’s door and entered, closing the door behind him. He remained in the room for approximately 12 minutes before a CNA entered the room while passing ice water. The CNA reported observing the EVS housekeeper standing with his pants down and the resident lying in bed with his penis in her mouth; the CNA stated she gasped, the housekeeper said “Oh shit,” and ran into the bathroom with a “scary look” in his eyes. The facility’s incident report documented that a staff member walked into the resident’s room and observed the staff member with his pants down and it appeared the resident was engaged in oral sex. Review of police body camera footage from the same day captured the resident stating, “My mind is gone,” and telling the Administrator and a police officer, “I am not saying I enjoyed it. He enjoyed it,” and, “It ain’t about me, it is about him.” These observations and statements, combined with the resident’s documented cognitive impairment and need for supervision, demonstrate that the facility did not ensure the resident’s right to be free from sexual assault by facility staff.
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