Based on observations, staff interviews, and reviews of the Administrator and Director of Nursing (DON) Job Descriptions, the facility administration failed to manage the facility in a manner that protects residents and safeguards them from elopement. Specifically, the administration was aware that the front entry door did not have an operational Wander Guard system to ensure residents at risk for elopement were protected. Despite this known hazard, corrective measures were not implemented. Resident (R) (R1) was placed in imminent danger due to the facility's failure to implement interventions for R1 upon admission. …
F835 citations in Georgia
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F835 more often than its own record predicts
3.69 times the share F835 takes of citations nationally.
Of every deficiency written in Georgia in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F835 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 record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The facility failed to provide protective oversight including continued monitoring of Resident (R)#37's being transferred in a wheelchair to prevent a reoccurrence of injury. Resident #37 sustained a fractured left lateral malleolus Bimalleolar Ankle on 2/24/18 and a [MEDICAL CONDITION] ankle distal fibula on 5/14/18. The failure to monitor and provide adequate supervision and assistive devices to ensure safety and prevent accidents resulting in harm. …
Based on observations, interviews, record review and facility policy, Administration failed to ensure residents' environment on two of four halls (200, and 400) was clean, in good repair and homelike. Administration failed to ensure residents (R33 and R14) were free from sexual and physical abuse. Administration failed to ensure allegations of sexual abuse were thoroughly investigated for R33 and reported timely to the State Survey Agency (SSA) (R14 and R12). Administration failed to ensure residents (R53, R59, R12 and R2) care plans were developed for activities with interventions for residents that required diversional activities, activities in their rooms and activities that were appropriate for residents with dementia on the secure unit. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 1.19% | 4.14× |
| 2024 | 1.34% | 4.11× |
| 2025 | 1.09% | 3.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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