Based on observations, staff interviews, record review, and review of the facility's policy titled Elopement Prevention, the facility failed to implement adequate supervision and elopement prevention measures to safeguard one of three sampled residents (R) (R1). This failure allowed the resident to leave the facility without staff knowledge, resulting in an elopement.On July 23, 2026, 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, Director of Health Services (DHS), and Corporate Nurse Consultant were informed of the Immediate Jeopardy (IJ) on July 23, 2026, at 6:05 PM. …
F689 citations in Georgia
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F689 less often than its own record predicts
0.97 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F689 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 observation, staff and resident interviews, record review, and policy review, the facility failed to provide adequate supervision and implement appropriate safety measures to ensure residents remain free from preventable accidents and hazards for three residents (Resident (R) 49, R60, and R52) reviewed for accidents of 34 sample residents. Actual harm was identified to have occurred on July 26, 2026, when one Certified Nurse Aide (CNA) transferred R49 using a mechanical lift unassisted, resulting in the bar of the lift striking R49's forehead, causing a head laceration which required skin glue and wound closure strips. …
Based on interviews, record review, and policy titled, Accidents and Supervision the facility failed to ensure one of six sample residents (R) (R1) received adequate supervision outside to prevent potential accidents. s. This deficient practice had the potential to result in negative safety outcomes, such as falls, accidents and elopements.Findings Includes:A review of Policy titled, Accidents and Supervision revealed, the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes. 3. Implementing interventions to reduce hazard(s) and risk(s).4. Monitoring for effectiveness and modifying interventions when necessary.Policy Explanation and Compliance Guidelines. 5. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 3.58% | 0.72× |
| 2024 | 3.96% | 0.74× |
| 2025 | 5.37% | 0.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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