Chatuge Regional Nursing Home: Immediate Jeopardy - GA
Federal inspectors cited Chatuge Regional Nursing Home for immediate jeopardy violations on June 7, 2024, after finding the facility's administration failed to protect residents from abuse and exploitation. The citation means inspectors determined the facility's failures had caused or were likely to cause serious injury, harm, or death to residents.
The immediate jeopardy finding centered on two incidents from March 22, 2024. In the first, the facility failed to protect two residents from physical, mental, and verbal abuse. In the second, Certified Nurse Aide CNA1 began a personal relationship with resident R71.
But the exploitation allegation involving CNA1 and R71 had been reported to the administrator nearly eight months earlier, on July 12, 2023. The administrator failed to identify the personal relationship as potential exploitation and neither investigated nor reported the allegation, inspection records show.
The facility received a credible allegation of compliance on June 7, 2024, and inspectors validated that corrective plans had removed the immediate threat by June 8.
Beyond the immediate jeopardy violations, inspectors found widespread problems throughout the 104-bed facility during their June 8, 2024 complaint investigation.
Staff Ignored Doctor's Orders
A resident with cerebral palsy and no upper body core strength was repeatedly found without the body pillows his doctor had ordered to prevent aspiration. The physician's September 21, 2023 order specified bilateral body pillows should be placed under the fitted sheet when the resident was in bed for torso support, noting the resident had a gastric feeding tube and needed support to stay upright to help prevent aspiration.
Inspectors observed the resident without the required pillows on four separate occasions between June 5 and June 6. Certified Nurse Aide 5 told inspectors he didn't use pillows under the fitted sheet and wasn't aware of the physician order. Licensed Practical Nurse 3 said she was also unaware of the order and had never placed pillows under the resident's sheet.
Licensed Practical Nurse 5 confirmed she knew about the physician orders but didn't know why the pillows weren't in place or when they were removed.
Respiratory Equipment Left Dirty
A resident with chronic obstructive pulmonary disease received nebulizer treatments with equipment that wasn't properly cleaned or stored. The facility's policy required medication chambers to be rinsed with fresh tap water after each use, dried on clean paper towels, and stored in plastic bags marked with the resident's name and date.
On June 5, inspectors found the resident's nebulizer medication chamber still contained medication and hadn't been rinsed. The equipment wasn't stored in the required plastic bag.
The resident told inspectors that staff placed the medication chamber and tubing in a basket behind her bed without rinsing it. She said when she first received the device, instructions indicated to boil the mouthpiece and medication chamber for five minutes after use.
Registered Nurse 1 confirmed the medication chamber still contained medication and the equipment wasn't bagged. She acknowledged she should have rinsed the chamber after administering medication and properly stored the equipment.
Bed Rail Consents Missing
Four residents used bed rails without signed informed consent forms, despite facility policy requiring consent from residents or their representatives after discussing potential benefits and risks.
One resident with bilateral upper quarter rails told inspectors: "I hate these damn things, they antagonize me." When asked if anyone had explained the risks and benefits, he said: "No risk/benefits - I hate them damn things."
Another resident with one upper quarter bed rail said no one had reviewed risks or benefits with him.
A third resident fell out of bed and hit her cheek on the side rail. By the time inspectors returned, both rails had been wrapped in pipe insulation padding. Registered Nurse 1 explained: "The padding was added yesterday because she fell out of bed and hit her cheek on the siderail."
The Director of Nursing confirmed the facility should attempt alternatives before using side rails and that risk-benefit discussions should be documented. No signed consents were provided for any of the four residents by the end of the inspection.
Expired Medications Stockpiled
Inspectors found extensive expired medications and supplies throughout the facility. In the Blue Hall medication room, they discovered 23 different expired items, including protein supplements that expired in March and April 2024, acid reducer tablets that expired in December 2023, and an iron supplement that expired in February 2023.
A phlebotomy cart contained blood collection tubes that expired in December 2023 and others that had expired just days before the inspection. One medication cart had 78 discontinued narcotic pain medication tablets still available for use.
The Director of Nursing told inspectors expired medications should be removed immediately and shouldn't be available for use.
Meals Served Hours Late
Residents regularly received meals hours after scheduled times, with lunch sometimes served as late as 3 p.m. instead of the designated noon hour. The facility's registered dietician and dietary manager confirmed breakfast should be served at 8 a.m., lunch at noon, and dinner at 5 p.m.
On June 6, inspectors observed lunch trays arriving on the pink hall at 1:31 p.m. — an hour and a half late. The last tray was served at 1:51 p.m. The following day, lunch trays arrived on the green hall at 1:45 p.m., with the final tray served at 2:19 p.m.
Resident Council members confirmed meal delivery was consistently late. Two residents said late dinners affected their acid reflux. Two diabetic residents expressed concerns about receiving lunch so late after taking insulin, with one stating lunch sometimes arrived as late as 2:15 p.m.
Certified Nurse Aide 9 told inspectors room trays "always come late" and she'd seen them arrive as late as 3 p.m. Another aide said the late meal service made it difficult to complete other required resident care.
Eight residents were observed sitting outside their rooms waiting for lunch at 1:50 p.m. on June 7. One resident said "we always eat lunch late." Another agreed, saying "usually we don't get lunch earlier than 2:00 pm."
Family members visiting one resident were giving him a protein shake because lunch trays were consistently late. They told inspectors "that's too late for lunch," and the resident agreed.
Pharmacist Missed Medication Review
The facility's consultant pharmacist failed to identify that a resident had been receiving anti-anxiety medication lorazepam beyond the required 14-day limit without proper documentation. The resident had an order dated May 9, 2023 for lorazepam as needed for anxiety, but monthly medication reviews from May 2023 through May 2024 showed no pharmacist recommendations about the lack of a stop date or need for physician rationale to continue the medication.
The resident's physician confirmed he hadn't documented rationale for continued lorazepam use. The pharmacist verified monthly reviews didn't address the lorazepam and no recommendations were made.
Staffing Information Incomplete
The facility's daily nurse staffing posting failed to include required information. While the lobby posting showed numbers of registered nurses, licensed practical nurses, and certified nurse aides for each shift, it didn't display the facility name, daily census, or total hours worked by each staffing category.
The Director of Nursing confirmed the posting didn't contain all required elements, and the human resources staff member responsible for the posting said there was no policy regarding nurse staff posting requirements.
The facility houses 104 residents in Hiawassee, a small mountain community in north Georgia near the North Carolina border.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chatuge Regional Nursing Home from 2024-06-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CHATUGE REGIONAL NURSING HOME in HIAWASSEE, GA was cited for immediate jeopardy violations during a health inspection on June 8, 2024.
The citation means inspectors determined the facility's failures had caused or were likely to cause serious injury, harm, or death to residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.