Based on record review, staff interviews, and review of the job description for the Director of Nursing, the facility failed to ensure clinical staff were trained and competent to provide emergency care for accidental trach dislodgement for one of three residents (R) R2 reviewed for tracheotomy care. The facility's failure to properly train staff for complex care of tracheostomies and emergency airway maintenance resulted in R2 trach becoming dislodged, and R2 required surgical intervention to reinsert tracheostomy tube. The facility's failures created potential risks for the safety and well-being of the residents and resulted in Immediate Jeopardy. …
F940 citations in Georgia
Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F940 less often than its own record predicts
0.58 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia in 2025, this is the portion that was F940.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F940 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 a review of the facility's Facility Assessment, the facility failed to ensure the physical therapy staff were informed or educated prior to applying an electronic medical device for electrical stimulation treatment (also known as e-stim, which is a treatment method often used in physical therapy and pain management to deliver mild electrical currents through the patient's skin to either target the muscles to stimulate quicker recovery or the nerves to reduce pain) for one of one resident (R) (R 14). Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an e-stim treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. …
Based on staff interviews and review of the facility's policies titled, Nursing Care Center Pharmacy Policy and Procedure Manual, Facility Assessment and Rules and Regulations of the State Of Georgia, the facility failed to provide evidence of implementation and maintenance of an effective training program for three of thirty Certified Medication Aide Techs (CMAT LL, CMAT MM, and CMAT NN) selected for review of their medication administration skills competency check off. The deficient practice had potential to adversely affect the care given to all residents in the facility. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 3.19× |
| 2024 | 0.34% | 3.56× |
| 2025 | 0.06% | 0.58× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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