Based on interviews, record review, and the review of the facility policies titled Activities of Daily Living (ADL) and Assistance with Meals, the facility failed to provide supervision and assistance with Activities of Daily Living (ADL) care during meals for one of 45 residents (R) (R200) related to a diagnosis of dysphagia (difficulty swallowing). On [DATE], this failure resulted in R200's death by choking on a sandwich. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 10:25 am. …
F677 citations in Georgia
ADL care for dependent residents · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F677 more often than its own record predicts
1.29 times the share F677 takes of citations nationally.
Of every deficiency written in Georgia in 2025, this is the portion that was F677.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F677 findings written in Georgia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observations, interviews, and record review, the facility failed to ensure that five of 43 sampled residents (R) (R30, R24, R4, R25, and R31) were provided Activities of Daily Living (ADL) care. Psychosocial harm was identified for R30 related to her becoming tearful and expressing feelings of humiliation when she was ignored, and staff refused the resident incontinence care. Findings included: A review of the facility policy last updated December 2022 titled, Quality of Life-Dignity, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be always treated with dignity and respect. …
Based on observations, staff and resident interviews, record review, and review of the facility policy titled ADL Plan of Care, the facility failed to provide Activities of Daily Living (ADLs) care pertaining to showers and/or bed baths for two of 17 sampled residents (R) (R35 and R54). The deficient practice increased the risk to compromise the dignity and psychosocial well-being for R35.Findings include: A review of the facility policy titled, ADL Plan of Care review dated 12/27/2025, documented under Intent: Develop and communicate patient needs for assistance with ADLs. 1. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 2.90% | 1.04× |
| 2024 | 3.16% | 1.30× |
| 2025 | 2.91% | 1.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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