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
A resident with severe dementia, paraplegia, underweight/low BMI, dysphagia, and a Stage IV sacral pressure ulcer had a care plan that included infection-prevention measures such as ordered wound treatments, specialized mattress use, positioning devices, and enhanced barrier precautions. During an observed wound care procedure, an LPN removed a soiled dressing, changed gloves multiple times, and cleansed and redressed the wound but did not perform hand hygiene between glove removals and re-gloving. In interviews, the LPN reported being unaware that hand hygiene was required between glove changes, and the RN acting as DON confirmed that facility policy and infection control standards require hand hygiene between glove changes.
A resident with multiple psychiatric and cardiac diagnoses had an annual MDS completed with Section E (behavioral symptoms) coded as showing no behaviors, despite EMR documentation of hostility, disorientation, incontinence, paranoid statements, and unsafe smoking behavior involving staff intervention. The MDS Coordinator later acknowledged that the documented behaviors should have been coded on the MDS, and leadership stated that accurate behavior coding would have triggered a new care plan, while also noting the facility relies on the RAI Manual rather than a specific internal MDS policy.
Dietary staff did not follow the facility’s equipment cleaning policy requiring freezer elements to be kept free of frost and ice build-up. Surveyors observed two separate kitchenette countertop freezers, each with three shelves, where the middle shelf was completely covered with thick frost and ice cream cups were stored within or on the frost. During interviews, the DM confirmed the frost build-up and the storage of ice cream cups in the frost, and reported that these freezers were only cleaned and defrosted when visible frost appeared, with no established defrosting schedule.
A facility failed to develop and implement complete, resident-specific care plans for ADL refusals, ROM, and nail/oral care. One resident with severe cognitive impairment and multiple psychiatric and mobility diagnoses had no care plan addressing intermittent verbal refusal of ADL care, and during agitated care assistance, slid from a wheelchair and sustained a right femur fracture. Another resident with quadriplegia, hand contractures, and diabetes was observed with tightly fisted hands without splints or rolls, and received AM care without hand washing, mouth care, or foot care, despite dependence for hygiene and a care plan that lacked ROM or contracture interventions and resident-specific nail care directions. A third resident with vascular dementia and respiratory disease had long, jagged fingernails and overgrown, discolored toenails curling into the skin, while the care plan only generally directed staff to check nails for cleanliness; CNAs gave conflicting accounts of who was responsible for nail care, and nursing leadership confirmed the absence of resident-specific nail care interventions or documentation of refusals.
A resident with severe cognitive impairment, dementia, and dependence for dressing was being assisted with a pull‑over shirt by a CNA while already agitated and resisting care. Despite prior in‑service training and facility policies directing staff to stop care, ensure safety and dignity, and obtain help when a resident becomes combative or agitated, the CNA continued the dressing task as the resident pushed against her, leading to the resident sliding from the wheelchair to the floor. The resident was initially documented as having no apparent injury, but later complained of right leg pain, and imaging confirmed a right supracondylar femur fracture.
The facility failed to prevent sexual abuse when a cognitively impaired resident with dementia and behavioral disturbances repeatedly wandered into other residents’ rooms and got into their beds, often lying on top of them, despite ongoing documentation and staff awareness of these behaviors. Nursing notes and staff interviews described this pattern as common, with redirection attempts by CNAs and LPNs noted as unsuccessful. Another cognitively impaired resident was later found in bed with this resident on top of her, his pants down and attempting to kiss her while she screamed, and prior concerns had been raised by her family about unexplained blood on her lip and changes in her condition. These events occurred even after environmental changes to a previously locked dementia unit, while staff continued to regard the behavior as typical for the resident.
Two residents were not protected from abuse when one, who had moderate cognitive impairment and required extensive ADL assistance, reported that a CNA refused to help her back to bed and twisted her arm, resulting in a skin tear and bruising in a fingerprint pattern, and another nonverbal resident with hemiplegia confirmed by nodding that a CNA had yelled at her to “shut up.” These incidents occurred despite facility policies stating that abuse, neglect, and exploitation are prohibited and that such occurrences will be analyzed to prevent recurrence and reported when there is reasonable suspicion of a crime.
Surveyors found that dietary staff, including a cook and the FSD with facial hair, repeatedly worked in the kitchen without required beard restraints during multiple observations. On several occasions, staff with beards were seen in food preparation and service areas, including while one cook leaned over a steam table to take temperatures on multiple food items, bringing his beard close to hot foods. Facility policy required all dietary staff to wear hair restraints, including beard restraints, and prohibited bare-hand contact with food, but these requirements were not followed, creating a potential for food contamination affecting all residents served.
Surveyors found that pureed foods for eight residents on puree or mechanical diets were not prepared according to the facility’s written puree guidelines and recipes. A cook prepared pureed pulled pork, carrots, and baked beans without using recipes, did not measure ingredients to achieve the required consistency, and described the target texture only as a “peanut butter consistency.” The cook also failed to perform proper hand hygiene before resuming work after retrieving supplies and between preparing different pureed items, and rinsed utensils in a sink during preparation. Policy required specific additives and methods to conserve nutritive value, flavor, and appearance, and leadership confirmed that pureed foods were expected to be prepared per recipe.
Surveyors found that the facility did not follow its own bed-hold policy for two residents with moderate cognitive impairment who were transferred to the hospital. The policy required that written information explaining bed-hold rights, state reserve bed payment rules, and the facility per diem rate be given to residents and their representatives before transfer. For one resident who was his own responsible party, there was no documentation that a written bed-hold notice was provided at the time of transfer or during the subsequent hospitalization. For another resident whose sister was listed as the primary contact, records lacked any confirmation that the bed-hold notice was reviewed with or signed by either the resident or the sister on the day of transfer, and the DON and Administrator confirmed that no such documentation existed.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves failure to follow appropriate hand hygiene practices during wound care for a resident with a Stage IV sacral pressure ulcer. The resident’s EMR showed multiple diagnoses including late-onset Alzheimer’s disease, severe dementia, paraplegia, peripheral vascular disease, underweight/low BMI, dysphagia, and a Stage IV sacral pressure ulcer. The care plan included interventions to reduce risk of complications and infection, such as weekly wound assessments, ordered treatments, use of a low-air-loss mattress, positioning/off-loading devices, maintaining cleanliness and dryness, enhanced barrier precautions, nutritional support, and coordination with hospice and the wound provider. Wound provider documentation shortly before the observation described the sacral pressure injury as Stage IV, with mild serous drainage, no odor, no peri-wound erythema, and noted the wound as improving. During an observed wound care procedure, the LPN wound care nurse donned gloves and removed the soiled dressing, then removed those gloves and put on a new pair without performing hand hygiene between glove removal and re-gloving. After cleansing the wound per treatment order, the LPN again removed and replaced gloves without performing hand hygiene between glove changes. The dressing was then applied, the resident was repositioned, and the soiled dressing was removed from the room. In an interview following the observation, the LPN stated she was unaware that hand hygiene was required between removing and donning new gloves during wound care. In a separate interview, the RN corporate nurse acting as DON confirmed that the expectation was for licensed nursing staff to perform hand hygiene between glove changes in accordance with infection control standards and facility policy.
Failure to Accurately Code Behavioral Symptoms on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when completing the annual MDS. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, hypertensive heart disease with heart failure, and adjustment disorder with depressed mood. The annual MDS with an ARD of 6/17/2025 coded Section E, Behavioral Symptoms, as 0, indicating that no behaviors were exhibited. However, review of the EMR showed that this coding did not reflect the resident’s documented behavioral status. The EMR contained a behavior note dated 06/11/2025 describing the resident as very hostile and disoriented, incontinent in bed, and expressing paranoid statements that people were hiding things from her. The note further documented that the resident went behind the nurses’ station, took cigarettes and a lighter despite a CNA telling her not to, lit a cigarette, walked down the hall smoking, and became very hostile when the Administrator and Charge nurse attempted to take the lit cigarette from her, cursing before returning to her room. During interviews, the MDS Coordinator confirmed that this behavior note should have been reflected in Section E of the annual MDS, and the DON and MDS Coordinator acknowledged that accurate coding of behaviors in Section E would trigger the need for development of a new care plan. The Administrator stated that the facility does not have a specific internal MDS policy and relies on the RAI Manual for guidance.
Improper Frost Build-Up Management in Kitchenette Freezers
Penalty
Summary
Dietary staff failed to maintain kitchenette freezers free of frost build-up as required by the facility’s policy titled “Cleaning Procedures: Major Equipment,” which states that walk-in freezers must be kept free of frost and ice build-up on a daily basis. During observation of the kitchenette serving the 500, 700, and 800 halls, surveyors noted a small countertop freezer with three shelves in which the middle shelf was fully covered with approximately one inch of frost, and ice cream cups were stored within the frost. In a separate kitchenette serving the 100, 200, 300, and 400 halls, another small countertop freezer with three shelves was observed, with the middle shelf fully covered with a thick layer of frost and ice cream cups stored on the frost. In interviews conducted at the time of each observation, the Dietary Manager confirmed the presence of frost build-up and the storage of ice cream cups within or on the frost in both freezers, and stated that these freezers were cleaned and defrosted only when visible frost was noticed, with no set schedule for defrosting. No specific residents or their medical conditions were mentioned in the report, and the deficiency centers on the condition and maintenance of the dietary equipment rather than on individual resident care events.
Failure to Develop and Implement Resident-Specific Care Plans for ADL Refusals, ROM, and Nail/Oral Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, resident-specific care plans addressing all identified needs, including refusals of care, range of motion (ROM), and nail and oral care. For one resident with Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and gait/mobility abnormalities, the quarterly MDS showed severe cognitive impairment with an inability to complete the BIMS interview. Despite this, the care plan did not include interventions for intermittent verbalization or refusal of ADL care. On the morning of 1/13/2026, a CNA reported that when she entered this resident’s room, the resident was already agitated, and during an attempt to assist with ADL care, the resident slid from the wheelchair onto the floor. Progress notes documented a witnessed fall while the resident was being adjusted in the wheelchair, resulting in a supracondylar fracture of the right femur. For a second resident with aphasia following cerebral infarction, quadriplegia related to CVA, hand contractures, multiple-site muscle contractures, and type 2 diabetes, observations on multiple dates showed the resident lying on his back with both hands tightly closed in fists and no splints or rolls in place. During AM care, staff did not wash the resident’s hands or provide mouth or foot care, and when socks were removed, the great toe nail was thickened with debris buildup and yellowish discoloration. The MDS documented severe impairment in decision-making and total dependence on staff for personal hygiene, including nail care. The care plan identified dependence for dressing, oral hygiene, personal hygiene, and bathing, and directed staff to check nails for cleanliness, but contained no interventions for upper extremity contractures or ROM. An LPN confirmed there were no resident-specific interventions for nail care, no care plan for contractures, and no documentation of care refusal or attempted interventions. For a third resident with vascular dementia, emphysema, and COPD, observations showed long, jagged fingernails and overgrown toenails on both feet that were curling into the skin, cloudy/tan in color, and curling up on the sides, pulling away from the nailbed. The admission MDS showed moderate cognitive impairment and a need for staff assistance with setup/cleanup for personal hygiene. The care plan, initiated after a decline in ADL self-care related to recent hospitalization, stated that staff should check nails and ensure they are clean and that the resident required staff assistance for ADL care. Interviews with CNAs revealed inconsistent understanding of who was responsible for nail care, with one CNA stating she usually did nail care during showers but not toenails, and another stating she trimmed the resident’s nails, that it was painful for the resident, and that she did not know who normally trimmed the resident’s nails. The DHS and an LPN acknowledged that the resident did not have resident-specific interventions for nail care and that there was no documentation of refusal of care or attempted care-planned interventions, despite facility policies requiring comprehensive, resident-specific care plans and timely updates with changes in condition.
Failure to Follow Dementia Care and Safety Interventions During ADL Assistance Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and interventions were provided during ADL care, resulting in a fall and right femur fracture. On the morning of 1/13/2026, progress notes documented that the resident slid from her wheelchair to a sitting position on the floor while being adjusted in the wheelchair, with no apparent injury and no pain reported at that time; she was assisted back into the wheelchair. Later that morning, the resident complained of right leg pain, was given Tylenol, evaluated by the Nurse Practitioner, and an x‑ray was ordered. That evening, the x‑ray confirmed a supracondylar fracture of the right femur, and an IDT fall note later documented that the resident was sent to the emergency room for evaluation and treatment. The resident had been admitted with diagnoses including Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and gait/mobility abnormalities. A quarterly MDS dated 1/6/2026 showed a BIMS score of 99, indicating severe cognitive impairment, severely impaired daily decision‑making, continuous inattention with disorganized thinking, and dependence for upper and lower body dressing. Despite this profile, during a telephone interview the CNA who provided care on 1/13/2026 stated that when she entered the resident’s room, the resident was already agitated. The CNA reported that she was putting a pull‑over shirt on the resident while the resident was pushing against her to get the shirt off, and as the CNA continued to push the shirt down, the resident slid from the wheelchair onto the floor on her left side. The CNA stated she called for the nurse, who assessed the resident and found no injury, and the resident was assisted from the floor back into the wheelchair. The CNA further reported that she and another CNA later assisted the resident to the edge of the bed, at which point the resident began complaining of right leg pain and the nurse was notified. The CNA acknowledged she had received education on caring for combative or agitated residents, including in‑services instructing staff to stop care, ensure safety and dignity, and obtain help when a resident becomes combative or agitated. Facility leadership, including the Education Coordinator and DHS, stated their expectation that staff stop what they are doing, ensure the resident’s safety, and seek additional help when a resident is agitated, resistant to care, and unable to be redirected. Facility policies on Occurrences and Dementia Care emphasized assessing risk, implementing appropriate interventions, and using respectful, patient approaches for residents with dementia, but these expectations were not followed during the incident.
Failure to Prevent Ongoing Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent sexual abuse between residents and to protect residents from non-consensual sexual contact as required by its Abuse, Neglect, and Exploitation policy. The policy states the facility will prohibit and prevent abuse, neglect, and exploitation, including non-consensual sexual contact of any type with a resident. Despite this, one resident (R1), who had significant cognitive impairment with a BIMS score of 08 and diagnoses including vascular dementia, bipolar disorder, anxiety disorder, and dementia with behavioral disturbances, repeatedly entered other residents’ rooms and beds. Nursing notes over several months documented R1 attempting to go into other residents’ rooms, climbing into their beds, wandering hallways, and being found lying on top of other residents, both male and female, with staff redirection attempts noted as unsuccessful. Multiple nursing notes described specific incidents where R1 was found in bed with other residents. On one occasion, a nurse documented that R1 was found in another patient’s room lying asleep on top of another patient and was assisted off. Another note the same date documented that another patient was in R2’s room and laid down on top of her and went to sleep, and that the other patient was removed and returned to their room. Subsequent notes indicated that R1 continued to try to get into bed with residents and that he was wandering up and down hallways and going in and out of other residents’ rooms, with continued attempts to enter a specific female resident’s room despite redirection. Staff interviews confirmed that it was common and “normal” for R1 to get in and out of bed with other residents and to lie on top of them, and that CNAs routinely reported these behaviors to nursing staff. R2 was a resident who could not complete the BIMS, indicating significant cognitive impairment. A nurse note documented that R2’s daughter was concerned after finding blood on R2’s bottom lip and that R2 was not herself. Later, a nurse note recorded that R2’s responsible party was notified that another resident had been found in bed with R2, with his pants down and his lips on hers. The facility’s investigation included a CNA’s written statement that R1 was found in R2’s bed with his pants and underwear off, on top of R2, holding her by both arms and attempting to kiss her while R2 screamed. Another CNA interview described finding R1 on top of R2 with her arms pinned down, his face very close to hers, and his pants pulled down. Staff, including the Social Services Assistant and LPNs, acknowledged that R1’s behaviors of getting into bed with other residents were ongoing, that redirection was ineffective, and that these behaviors occurred both when R1 was on a locked dementia unit and after the unit doors were removed, yet R1 continued to have access to other residents and their rooms.
Failure to Protect Residents From Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, resulting in physical harm to one resident and verbal abuse of another. One resident with acute embolism and thrombosis of the right femoral vein, history of pulmonary embolism, fibromyalgia, major depressive disorder, and dementia with agitation had a quarterly MDS showing moderate cognitive impairment and dependence on staff for transfers and significant ADL assistance. Facility documents show that this resident reported asking a CNA for assistance back to bed, and the CNA told her she could put herself in bed and then twisted her arm. A head-to-toe assessment identified a skin tear on the right arm where the resident reported the CNA twisted her arm, and a subsequent skin assessment documented bruising in a fingerprint pattern around the skin tear. During multiple later observations and attempted interviews, the resident either did not answer questions about the incident or refused to discuss it. The deficiency also includes an incident of verbal abuse toward another resident who had been admitted with essential hypertension, GERD, asthma, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. The Social Worker District Coordinator reported being informed by staff that a CNA yelled at this resident to “shut up.” The SDC interviewed the resident, who is nonverbal, and the resident confirmed the allegation by nodding yes. The Administrator was notified and also interviewed the resident, who again confirmed the verbal abuse allegation by nodding. The facility’s written policies on Abuse, Neglect and Exploitation and on Reporting Reasonable Suspicion of a Crime state that the facility will prohibit and prevent abuse, neglect, and exploitation of residents and will analyze occurrences to determine why abuse occurred and what changes are needed to prevent further occurrences, as well as report any reasonable suspicion of a crime against a resident.
Failure to Enforce Beard Restraints for Dietary Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to ensure kitchen staff wore appropriate beard restraints in accordance with professional standards and facility policy. During an initial kitchen tour on 2/15/2026 at 11:39 a.m., a cook and the Food Service Director (FSD) were observed to have facial hair without beard nets. On 2/16/2026 at 10:49 a.m., during a comprehensive kitchen tour, another cook and the FSD were again observed with facial hair and no beard nets. Later that day at 12:05 p.m., during a food temperature observation, both cooks and the FSD were observed not wearing beard restraints while one cook took temperature readings for fifteen food items, leaning over the steam table so that his beard came into proximity to hot foods. The facility’s written policy on Dietary Employee Personal Hygiene, revised 9/1/2025, stated that all dietary staff must wear hair restraints, including beard restraints, to prevent hair from contacting food, and that employees should never use bare hand contact with any foods. The facility had a census of 127 residents at the time of the survey, and the surveyors determined that the failure to use beard nets had the potential to contaminate food and cause food-borne illnesses.
Failure to Follow Puree Food Preparation Guidelines and Recipes
Penalty
Summary
Surveyors identified a deficiency in the facility’s preparation of pureed foods for eight residents on puree or mechanical diets. The facility’s policy and guidelines for Puree Food Preparation required that pureed foods be prepared in a manner that conserves nutritive value, palatable flavor, and attractive appearance, and specified the type and amount of ingredients to be added to different food categories (such as broth or gravy for meats and poultry, margarine for noodles and root vegetables, mashed potato flakes for certain vegetables, and thickener for most fruits). During review, it was noted that the policy had been updated, and the Administrator stated that pureed foods should be prepared in accordance with recipes to present food integrity and nutritive value. During an observed puree food preparation session, a cook with five months’ tenure at the facility and five years’ experience as a cook prepared three pureed items: pulled pork, carrots, and baked beans, for eight residents receiving pureed diets. The cook did not have all supplies ready before starting, stopped production to retrieve beef base, and failed to perform hand hygiene before resuming preparation and between preparation of each pureed item. He used a sink to rinse utensils during the process, did not use a recipe, and did not measure ingredients to ensure appropriate consistency. When asked about the expected consistency, he described it as a “peanut butter consistency” and acknowledged he did not know where the recipes were located, while the Food Service Director clarified that recipe books were stored on a shelving unit near the puree preparation area.
Failure to Provide Required Written Bed-Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notices to residents or their representatives upon transfer to the hospital, as required by its "Bed Hold and Returns Policy." That policy stated that prior to a transfer, written information must be given to residents and their representatives explaining the rights and limitations regarding bed holds, the state plan reserve bed payment policy, and the facility per diem rate to hold a bed or extend a bed hold. For one resident with a BIMS score of 07 indicating moderate cognitive impairment, records showed he was his own responsible party and was transferred to the hospital, where he remained until his death. Review of his clinical record, including progress notes, revealed no evidence that a bed-hold notice was provided on or around the dates of transfer and hospitalization. The DON acknowledged that the facility did not provide a written bed-hold notice before or on the date of transfer, and the Administrator confirmed there was no record of such a notice being given. For a second resident with a BIMS score of 10, also indicating moderate cognitive impairment, the face sheet identified the resident’s sister as the primary emergency contact and next of kin. Progress notes documented that this resident was transferred to the hospital, but the documentation lacked confirmation that the bed-hold notice was reviewed with or signed by either the resident or the sister on the day of transfer. In a joint interview, the DON and Administrator confirmed there was no documentation that the bed-hold policy was reviewed with or provided to the resident or the resident’s representative at the time of transfer. These findings showed that, for both residents reviewed for hospitalizations, the facility did not follow its own policy requiring written bed-hold information prior to transfer.
Some of the Latest Corrective Actions taken by Facilities in Georgia
Explore Popular Searches
