Citations in Georgia
Statistics, citations 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 and a known wandering/elopement risk eloped from the facility after staff lost track of the resident during the evening. Staff searched the building and grounds, notified law enforcement, and the resident was later found walking along a roadway in the rain. Surveyors also found multiple exit doors, only one audible alarm, delayed door closure on several exits, and nonfunctional cameras near most exits, while staff reported the resident frequently wandered, entered other residents’ rooms, and tested exit doors.
Failure to protect a resident from sexual abuse by another resident. A resident with severe cognitive impairment and depression was involved in two separate incidents with another resident who had documented hypersexual behavior, impaired cognition, and conflict with female residents. Staff witnessed one incident in which he attempted to get her to open her mouth so he could insert his penis, and another in which he exposed his penis to her; both allegations were substantiated.
Medication administration errors were observed for 3 of 32 opportunities, resulting in a 9.37% error rate. An LPN gave a multivitamin, aspirin chewable, and memantine 5 mg that did not match the physician orders on the MAR for two residents. The LPN confirmed the discrepancies, and the DON stated medications should match the orders and that the MAR had linked the wrong memantine strength to the pharmacy supply.
Failure to report an allegation of sexual abuse involving a second resident. Staff and resident interviews, along with record review, showed that an FRI addressed an incident involving one resident, but the DON’s email and resident statements identified another resident as also being involved in sexual activity with a male visitor. The facility did not include that resident in the FRI, despite a policy requiring all abuse allegations to be reported immediately to the Administrator and appropriate agencies.
Unsanitary areas, unsecured oxygen tanks, dirty IV stands, and leaking HVAC units were observed throughout the facility. The laundry room had debris on the floor, missing tiles, water damage, and a sink with stagnant water; the shower room had stained grout; empty O2 tanks were left unsecured outside the storage cage; two residents receiving enteral feedings had metal IV stands and bases with dried brown residue; and leaking AC/heating units in two rooms had basins placed underneath them. The DON and Maintenance Director confirmed several of these conditions.
Failure to protect resident privacy and confidentiality occurred when tracheostomy care was provided to two cognitively intact residents with the room door open and the privacy curtain not drawn, allowing the treatments to be visible. The facility also mistakenly mailed a room change notice containing another resident's name to an unauthorized family member, and the DON/Administrator confirmed the error.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to maintain an accident-free environment and provide adequate supervision to prevent accidents for one resident who was at risk for wandering and elopement. The resident had diagnoses including late-onset Alzheimer’s disease, severe dementia with agitation, anxiety disorder, insomnia, COPD, and a history of breast cancer. The resident’s BIMS score was 00, indicating severe cognitive impairment, and the record documented chronic confusion, frequent wandering, entering other residents’ rooms, repeated redirection, and elopement risk. On the evening of the incident, staff were unable to locate the resident after a CNA reported the resident missing. The facility searched the building, then expanded the search to the parking lots and surrounding area. Law enforcement was notified, and the resident was later found walking along a roadway in the rain and transported for evaluation. The emergency department record stated the resident had been missing for approximately three hours before being located. The investigation and observations identified that the resident had been wandering throughout the facility, pushing on exit doors, attempting to open doors, and sometimes trying to follow others through doorways. Staff interviews confirmed the resident routinely entered other residents’ rooms and tested exit doors. Survey observations also found multiple exit doors in the facility, with only one audible alarm, several doors with delayed closure, and cameras near most exit doors that were not functional. The facility was unable to determine the exact circumstances under which the resident exited the building.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to keep one of three sampled residents, R10, free from sexual abuse by another resident, R11. The cited policy stated that the facility was to protect residents from abuse and that sexual abuse is non-consensual sexual contact of any type with a resident. R10’s record showed diagnoses including unspecified altered mental status, depression, generalized anxiety disorder, and dementia with psychotic disturbance. Her MDS assessment showed a BIMS score of 0, indicating severe cognitive impairment, and a mood score of 17, indicating moderately severe depression. The record also showed that a Sexual Expression and/or Intimacy-Capacity to Consent Interview for R10 contained inappropriate responses and did not express a decision about her ability to consent to a sexual relationship. R11’s record showed diagnoses including stimulant abuse, prior cerebral infarction, TIAs, and vascular dementia, with a BIMS score of 11 indicating moderate cognitive impairment. His care plan documented hypersexual behavior, public displays of affection with another female resident, impaired cognitive function, and conflict with a particular female resident, with interventions focused on managing his behavior and protecting others. The facility documents described two separate resident-to-resident sexual abuse incidents involving R11 and R10. In one incident, an employee witnessed R11 attempt to get R10 to open her mouth so he could insert his penis, and in another incident staff witnessed R11 expose his penis to R10. The reports stated that staff intervened, the allegations were investigated and substantiated, and law enforcement and other parties were notified. The deficiency was based on the facility’s failure to keep R10 free from sexual abuse by R11 before and during these events.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors were observed for 3 of 32 medication opportunities, resulting in a 9.37% error rate. During an observation, an LPN administered One Daily Multivitamin with Minerals to R14 even though the EMR showed an order for a Multiple Vitamin tablet, 1 tablet by mouth daily for weight loss. The same LPN also administered Aspirin 81 mg chewable tablet to R13, while the EMR showed an order for Aspirin EC 81 mg delayed-release tablet, 1 tablet by mouth daily for essential hypertension. The LPN also administered Memantine 5 mg to R13 even though the EMR showed an order for Namenda (Memantine HCl) 10 mg tablet, 1 tablet by mouth twice daily for vascular dementia. During interview, the LPN confirmed the discrepancies and stated the multivitamin, aspirin dosage form, and memantine strength did not match the physician orders. The DON stated medications should match physician orders and noted that the MAR had linked the 10 mg Namenda order to a 5 mg medication supplied by the pharmacy. The facility policy required comparison of the MAR and medication label with physician orders and use of the five rights during administration.
Failure to Report Sexual Abuse Allegation Involving a Second Resident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident, R14, after staff and resident interviews and record review showed that R14 was involved in the same incident documented for R8. The facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, required all allegations of abuse, neglect, exploitation, or mistreatment to be reported immediately to the Administrator and to appropriate agencies within required timeframes, but the facility did not include R14 in the Facility Reported Incident (FRI) dated 06/16/2026. The record showed that the FRI addressed an allegation involving R8 and documented that R8 told staff she had received money from male visitors from the community in exchange for sexual activity. The facility’s investigation included an email from the DON stating that during a verbal altercation between R8 and R14, both residents admitted to inviting men to the facility for sexual activity. During interviews, R14 stated that R8 invited a man into the facility and that she began oral sex before R8 took over, while R8 stated that R14 met a man through a dating app and performed oral sex on him. In a later interview with the Administrator and DON, R14 stated she performed oral sex on the man because R8 did it, and the Administrator and DON confirmed the facility had not included R14 in the FRI.
Unsanitary areas, unsecured oxygen tanks, dirty IV stands, and leaking HVAC units
Penalty
Summary
The facility failed to maintain the laundry services area in a clean, sanitary, and safe condition. During an observation of the clean side of the laundry room, several resident slippers, a gray plastic wash basin, dried soap residue, and a pressure reduction bootie were seen on the floor beneath the industrial washing machines. Tiles were missing beneath the right-side washing machine, an uncovered drain contained rusty water, and the wall behind the utility sinks showed significant water damage with staining and an open, deteriorated area. One utility sink contained stagnant water that was not draining, and a stack of mechanical lift slings was observed on the floor outside the clean area. The EVSD stated night shift staff were responsible for gathering these items and that it was not being completed. The [NAME] shower room was also observed to have unsanitary conditions. In one shower stall, a heavy black substance was seen on the grout lines on the left side, and yellow/pinkish staining was seen on the grout lines on the right side. The Maintenance Director stated he was not aware that the grout required replacement and reported that the issue had not been entered into TELS. The facility also had unsecured empty oxygen tanks stored outside beneath the walkway connecting the facility to the laundry room. The empty tank cage was completely full, and 19 empty oxygen tanks were found outside the cage, unsecured and not labeled to indicate they were empty. The Corporate Director of Respiratory confirmed the tanks were not secured and were unsafe. The facility also failed to maintain metal IV stands in a clean and sanitary condition for two residents receiving enteral feedings. R22 and R13 were repeatedly observed in bed with a metal IV stand beside them holding a container of brown-colored enteral formula. On multiple observations, the IV stand and base were unclean with accumulated dried brown residue consistent with spilled formula. The DON confirmed the stands and bases were unclean and stated nursing staff should clean the IV stand when formula is spilled to prevent drying, and that housekeeping or maintenance would need to remove dried substances if the formula had already dried. In addition, leaking air conditioning/heating units beneath the windows in two rooms were observed on multiple occasions with basins containing clear liquid placed on the floor, and one observation included a blanket beneath a basin. The Maintenance Director confirmed the units were leaking.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when respiratory treatments were performed in public view without privacy measures. R34 was admitted with paraplegia, acute and chronic respiratory failure, and tracheostomy status, and had a BIMS score of 12 out of 15 indicating cognitive intactness. R235 was admitted with chronic respiratory failure and tracheostomy, and had a BIMS score of 15 out of 15 indicating cognitive intactness. During observation, a Respiratory Therapist provided tracheostomy care to R235 with the room door open and the privacy curtain not drawn, then moved to R34 and performed tracheostomy care without closing the curtain between the two residents and without closing the room door. The facility also failed to protect R132's confidentiality when a 15-day room change notice letter containing R132's name was mistakenly mailed to another resident's family member. R132 was admitted with chronic respiratory failure, gastrointestinal hemorrhage, and functional quadriplegia, and was assessed as being in a persistent vegetative state with no BIMS interview conducted. R132's responsible party reported concern that the resident's name appeared in the letter sent to the other resident's family member, and the Administrator confirmed the facility had mistakenly sent the notice containing R132's name to that individual.
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Compliance trends in Georgia
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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