Based on observations, record reviews, staff interviews, and review of the facility's policies Modified Texture of Food and Resident Food Preferences, the facility failed to provide a pureed snack to one of 26 sampled residents (R) (R165) ordered to receive a mechanically altered diet. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on [DATE]. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. …
F684 citations in Georgia
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F684 less often than its own record predicts
0.53 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F684 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, staff and family interviews, record review, and review of the facility's policies titled, Notification of Changes, Change in Resident's Condition or Status, the facility's Senior Medical Systems Protocols, and New Facility Procedure, the facility failed to ensure timely assessment, monitoring, escalation, and clinical management of a resident (R) (R3) who exhibited a progressive change in condition. Harm was identified to have occurred on [DATE], when R3 was hospitalized due to a fall after a decline in condition. Findings included:Review of the facility investigation documents revealed R3 sustained a fall on [DATE] (the facility-reported incident submitted to the State Survey Agency incorrectly documented the date of the fall as [DATE]). …
Based on observations, interviews, record review, and review of the facility policies titled, Weight Monitoring Program and Fluid Restrictions, the facility failed to ensure one of four residents (R) R17 received treatment and care in accordance with the physicians' orders. Specifically, the facility failed to ensure physician ordered daily weights were obtained and failed to implement and monitor a physician-ordered fluid restriction for R17.Findings included:Review of the facility policy titled Weight Monitoring Program revised 06/02/2023, stated that each resident is to be weighed once a month unless otherwise ordered by the physician.Review of the facility policy titled, Fluid Restrictions revised 03/24/2016 stated that physician ordered fluid restrictions would be ordered and… …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 2.47% | 0.68× |
| 2024 | 1.95% | 0.49× |
| 2025 | 2.29% | 0.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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