Based on record review and staff interviews, the facility failed to provide sufficient nursing staff to monitor one of 23 residents (R) (R1) on A Hall (the secured memory unit), resulting in R1 choking and expiring on 10/25/2025. Specifically, the facility failed to have sufficient nursing staff to provide nursing and related services, considering the number, acuity, and diagnoses of the facility's resident population. The facility's failure to provide sufficient nursing staff and related services caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy (IJ) was identified on 11/13/2025 and was determined to have existed on 10/25/2025. The Administrator and Regional Operations Manager were informed of the IJ on 11/13/2025. …
F725 citations in Georgia
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F725 less often than its own record predicts
0.44 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F725 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 resident and staff interviews and record reviews, the facility failed to provide staff in sufficient numbers to care for the needs of eight Residents (R) F, R H, R J, R E. R K, R A, R B, and R D. Actual harm was identified on 3/25/18 when the R F was being assisted by one Certified Nursing Assistant (CNA), rather than by two persons per the care plan, and fell out of bed resulting in a femur fracture. The facility census 86. Findings include: 1. Review of R F quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicates the resident's cognition was moderately impaired. …
Based on observations, resident interviews, staff interviews, record review, and policy review, the facility failed to provide sufficient nursing staff to meet the needs of residents. Specifically, the facility had multiple vacant nursing positions and did not have an established, planned staffing level to determine the number and type of nursing staff needed to meet residents' needs. During the review period, residents experienced delays in activities of daily living (ADL) care, repeated delays in medication administration, and a failure to provide ordered nursing services, including enteral nutrition. The facility census was 208 residents. Findings included:1. 1. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 0.32× |
| 2024 | 0.60% | 0.76× |
| 2025 | 0.34% | 0.44× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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