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
Failure to Notify Physician and Family of Resident’s Decline: A resident with multiple chronic conditions developed several days of nausea, vomiting, poor PO intake, weakness, and overall decline, but the record showed no timely MD/NP notification or increased monitoring before an unwitnessed fall. Therapy and nursing notes documented ongoing symptoms, yet only one-time Zofran was given and vital signs were not recorded during the decline. The resident later fell while vomiting, sustained facial and cervical injuries, and was hospitalized with severe electrolyte abnormalities, AKI, aspiration pneumonia/pneumonitis, respiratory failure, septic shock, and prolonged critical illness.
A resident with intact cognition, high fall risk, and multiple mobility and medical issues developed several days of nausea, vomiting, poor intake, weakness, and decline, but the record showed no timely comprehensive assessment, vital sign monitoring, or provider escalation. Nursing and therapy notes documented ongoing symptoms, meal refusals, and limited treatment with ondansetron, yet there was no clear follow-through before the resident had an unwitnessed fall while trying to vomit in the bathroom and was sent to the hospital with serious injuries and severe metabolic abnormalities.
Failure to Protect a Resident from Sexual Abuse: A resident with moderate cognitive impairment and dependence for ADLs was kissed on the mouth by another resident while lying in bed. Staff observed the interaction, removed the other resident, and the resident stated the contact was unwanted and non-consensual and that she could not express no. The other resident admitted to the kissing and minimized the behavior despite knowing the resident could not consent.
A resident with wounds and skin breakdown received perineal care from two CNAs who wore gloves but not gowns, despite EBP criteria being met. One CNA then left the room wearing soiled gloves, carried soiled linen and a brief into the hallway, disposed of them in hallway receptacles, and only then removed the gloves and performed hand hygiene. The resident had diagnoses including pressure ulcers, diabetes, and CKD, and the DON confirmed the resident should have been on EBP.
Expired and damaged food items were found throughout kitchen storage areas, including juice, tortillas, chips, muffin mix, milk, apples, butter, and bacon past their expiration dates. A Dietary Aide was also observed using a dented can of sliced apples in muffins, and another dented can was found on a stockroom shelf. The facility’s policy required proper dating, FIFO rotation, and separate storage of bent or damaged cans.
Wet-Nested Steam Table Pans Stored in Dietary Area: Dietary staff failed to prevent wet-nesting of stored steam table pans, despite facility policies requiring dishware and serviceware to be air dried before storage. During observation, multiple stacks of steam table pans were found with moisture inside, and an LDM confirmed the pans were stored wet. A dietary staff member was then observed wiping a wet pan dry with a towel, while the DM confirmed towels were not to be used and all dishes should be air dried.
Failure to Notify Physician and Family of Resident’s Decline
Penalty
Summary
The facility failed to ensure timely physician and responsible party notification when a resident experienced a significant decline in condition before an unwitnessed fall and hospitalization. The resident was admitted with multiple chronic conditions, including cognitive communication deficits, generalized weakness, hypertension, myasthenia gravis, difficulty walking, impaired coordination, multiple orthopedic conditions, blindness in one eye, and need for assistance with personal care. The resident’s care plan identified high fall risk related to impaired mobility, weakness, impaired coordination, visual impairment, prior falls, polypharmacy, dizziness risk, and myasthenia gravis. In the days before the fall, documentation from therapy, nursing, and meal records showed persistent nausea, vomiting, decreased appetite, poor oral intake, weakness, and a general decline in condition. Therapy notes repeatedly documented nausea and low energy, and nursing documentation showed a one-time dose of ondansetron was given for nausea. However, the record did not show ongoing assessment, provider notification, or increased monitoring despite continued symptoms over several days. Vital signs were not recorded between 2/16/2026 and 2/19/2026, even though the resident was symptomatic and declining, and the only communication record entry related to the resident was after the fall. On the evening of the fall, the resident was reported to have been vomiting, felt unwell, and was carrying a basin while attempting to vomit into the toilet when she became entangled in her pant leg and fell. She sustained facial swelling, an eye injury, laceration, and bruising to the neck, and EMS transferred her to the hospital. Hospital records showed facial fractures, a closed odontoid cervical spine fracture, severe hyponatremia, hypokalemia, acute kidney injury, aspiration pneumonia/pneumonitis, acute hypoxemic respiratory failure requiring intubation, septic shock, and prolonged critical illness. Interviews with staff and the resident’s daughter confirmed that the resident had been feeling unwell for several days, that staff were aware of the symptoms, and that the daughter was not notified of the resident’s decline before the fall.
Failure to Assess and Escalate Progressive Nausea, Vomiting, and Decline
Penalty
Summary
The facility failed to ensure timely assessment, monitoring, escalation, and clinical management of a resident who developed a progressive change in condition marked by repeated nausea, vomiting, weakness, and poor oral intake before an unwitnessed fall and hospitalization. The resident had a BIMS score of 14, required assistance with ADLs, used a walker and wheelchair, and was identified as high risk for falls. Her care plan included interventions for fall risk, weakness, fatigue, impaired balance, and monitoring for adverse medication effects, but the record showed repeated symptoms of nausea and decline without documented comprehensive assessment or escalation. Review of therapy notes, nursing documentation, CNA interviews, and the resident’s intake records showed several days of nausea, vomiting, abdominal discomfort, decreased appetite, meal refusals, and reduced intake. The resident was documented as not feeling well, nauseated, and having abdominal pain, and staff noted she requested Zofran and was drinking fluids. A one-time dose of ondansetron was given, and one nursing note stated the MD was aware and to continue the order, but the record did not show ongoing assessment, provider notification, or monitoring of the continued symptoms. Vital signs and blood pressure monitoring were not documented during the period of decline, despite the resident’s worsening condition. On the evening of the fall, the resident was found on the bathroom floor after an unwitnessed fall while attempting to vomit into the toilet and becoming entangled in her pant leg. Nursing documentation described facial swelling, eye injury, laceration, and bruising to the neck, and EMS transported her to the hospital. Hospital records showed severe hyponatremia, hypokalemia, acute kidney injury, weakness, continued vomiting, facial fractures, and a closed odontoid cervical spine fracture, followed by aspiration, respiratory failure, ICU admission, septic shock, and death after withdrawal of life support. The record also showed no timely physician or NP notification, no documented change-in-condition follow-through, and no evidence of increased monitoring before the hospitalization.
Failure to Protect a Cognitively Impaired Resident from Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to ensure a resident remained free from sexual abuse when another resident entered her room and kissed her on the mouth without consent. The resident involved had a history of left-sided hemiplegia/hemiparesis following a cerebral infarction, seizure disorder, dysphagia, cognitive communication deficit, and generalized muscle weakness and wasting. Her MDS reflected a BIMS of 11, indicating moderate cognitive impairment, and her care plan identified her as high risk for abuse and non-consensual interactions because of impaired communication, cognitive deficits, and dependence on staff for ADLs. On the day of the incident, a CNA observed the other resident inside the resident’s room while she was lying in bed and saw him kissing her on the mouth. Staff immediately removed him from the room and initiated an abuse investigation. During interviews, the resident stated the kiss occurred on her lips, described it as a wet kiss, and said it was unwanted and non-consensual. She also reported feeling uncomfortable with the other resident being in her room and said she did not know how to express no. The other resident admitted to kissing her and acknowledged he knew the conduct was wrong because of her cognitive impairment. The resident was interviewed by facility leadership and law enforcement, and documentation reflected that she later received behavioral health services related to the incident. The other resident had a BIMS of 15 and was cognitively intact, but his care plan had included prior goals related to consensual intimacy and sexual expression with another resident. After the incident, he was noted to be non-receptive to redirection and stated he believed his actions were acceptable. Law enforcement responded to the facility, interviewed both residents, and arrested him after determining the contact was inappropriate and non-consensual.
Failure to Use EBP and Proper Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for one sampled resident with wounds and skin breakdown. During observation of perineal care for the resident, two CNAs provided cleansing after a bowel movement, changed the brief, and replaced the soiled draw sheet while wearing gloves but not gowns, even though the resident had wound-related conditions that met criteria for Enhanced Barrier Precautions (EBP). One CNA was also observed leaving the resident’s room wearing soiled gloves while carrying two bags containing soiled linen and a soiled brief, then walking down the hallway to dispose of the items before removing the gloves and performing hand hygiene. The resident had diagnoses including pressure ulcer of the left heel, pressure-induced deep tissue damage of the sacral region, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, chronic kidney disease stage 3b, and need for assistance with personal care. The resident’s MDS showed a BIMS score of 13, indicating little to no cognitive impairment, and the resident required partial to moderate assistance with ADLs. The care plan identified skin breakdown related to a surgical wound to the left leg, a left heel pressure ulcer, and a pressure ulcer in the perineal/buttocks area. The DON confirmed that the resident had wound care orders for the heels and should have been placed on EBP, but this was not implemented. The DON also confirmed staff should have worn gown protection during perineal care. Facility policy stated that EBP requires gowns and gloves during high-contact activities such as providing hygiene and changing briefs or linens, and the hand hygiene policy stated that gloves do not replace hand washing and that hand hygiene is required immediately after glove removal.
Expired and Damaged Food Items Found in Storage and Use
Penalty
Summary
The facility failed to discard expired food items in accordance with its policy titled, Receipt and Storage of Food and Supplies. During the initial tour, expired food products were observed in multiple storage areas, including four cartons of apple juice, six packs of flour tortillas, six bags of tortilla chips, three boxes of muffin mix, 38 half-pint chocolate milks, a box of apples, a bag of butter, and two packages of Canadian style bacon. These items had expiration dates ranging from 11/25/2025 to 05/14/2026 and were found in the dry storage area, refrigerator, walk-in cooler, and walk-in freezer. On a later inspection, a Dietary Aide was observed using a dented 104 oz. can of sliced apples in muffins, and the aide stated he had overlooked the dent in the can. Another dented can of sliced apples was also found on a stockroom shelf in the dry storage area. The facility policy stated that supplies should be labeled and dated, the FIFO method should be used, and bent or damaged cans should not be stored with other supplies.
Wet-Nested Steam Table Pans Stored in Dietary Area
Penalty
Summary
Dietary staff failed to prevent wet-nesting in stored steam table pans, contrary to the facility’s policies requiring dishware and serviceware to be air dried before storage. During observation of the pot and pan rack, several stacks of steam table pans were found pulled apart with moisture inside the pans, including one stack of four small square pans where the top pan was wet with large drops of water and the water coated the bottom of the next pan, and another stack of five small square pans where the second pan from the top was wet with large drops of water. The Dietary Manager confirmed that the pans were stored wet and stated that dietary staff were to allow pans to completely air dry before stacking and storing. At a later observation, a dietary staff member was seen wiping the identified wet steam table pan dry with a white linen towel. The staff member stated she had been told by the Dietary Manager that the pans needed to be dried, and the Dietary Manager confirmed she had instructed the staff member that the pans needed to be dry and assumed the pans would be re-washed and air dried. The Dietary Manager also confirmed that dietary staff were not to use a towel to dry dish items and that all dishes should be air dried.
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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 1 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 1-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 1 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 1 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 1 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).
Trusted data from CMS and state health departments
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