Tattnall Healthcare Center: Resident Abuse Substantiated - GA

The woman was R14. The man was R80. Both were residents at Tattnall Healthcare Center, a nursing facility on Memorial Drive in this small south Georgia city. What happened next, and what the facility knew in the weeks and months before it happened, is documented in a federal inspection report completed this past August.

The facility substantiated resident-to-resident abuse.

CNA1, the nursing assistant who responded to the yelling, described the scene in a written witness statement included in the facility's investigation. "On Friday August 23 one of our patient was found in another resident room," she wrote. "She was laying across him with her bottom pants off. I remove her from his bed and walk her to her room. His part was out and he has his hand on her bottom."

When inspectors interviewed CNA1 nearly a year later, in August 2025, her account shifted slightly. She said R14 was lying crossways on R80's bed with her head hanging off the side, and that R14 was across R80's upper legs, but that the residents' genitals were not touching. She also said she did not recall R80 having his hand on R14's buttocks, though her own written statement from the night of the incident said otherwise. Both residents, she told inspectors, were calm and not exhibiting any distress.

CNA1 said she helped R14 out of the bed, put a gown on her, and walked her out of the room.

R14's cognitive state is not detailed in the inspection report. What is documented is that at the time of the incident she could walk independently, that she wandered constantly, and that she regularly entered other residents' rooms. The Social Services Director, who also worked at the facility the night of August 23, told inspectors she was well aware of R14's wandering before the incident occurred. After it happened, she went to see R14 in her room. R14 was lying in her bed, talking calmly and randomly. The SSD noted no signs of distress or anxiety.

R80's record tells a different story about his awareness of what was happening. A quarterly assessment completed July 1, 2024, roughly seven weeks before the incident, showed he scored 13 out of 15 on a standardized cognitive test, indicating he was cognitively intact. The same assessment noted he had not exhibited physical, verbal, or other behavioral symptoms toward other residents. A capacity assessment completed that same day, also by the Social Services Director, found R80 had the capacity to consent to sexual intimacy.

When the SSD spoke with R80 after the incident, he denied any wrongdoing.

The nursing note documenting the incident was entered as a late entry. It was created on August 26, 2024, three days after it occurred, and listed an event time of 8:00 p.m. on August 23. The note described a female resident wandering into R80's room, removing her soiled brief, lying across his bed, and R80 rubbing her buttocks with his hand.

R80 was discharged from the facility on October 11, 2024, roughly seven weeks after the incident. He had been admitted with a diagnosis of chronic obstructive pulmonary disease.

The facility's investigation, which included staff witness statements and a review of both residents' records, ultimately concluded that what happened on the night of August 23 constituted resident-to-resident abuse. That finding is confirmed in the inspection report completed by federal surveyors on August 21, 2025, nearly a year after the incident itself.

The interim administrator who spoke with inspectors in August 2025 said she had not been working at the facility when R14 wandered into R80's room. She confirmed the investigation's finding. "The expectation," she told inspectors, "was for the facility to be free of abuse."

What the inspection report does not resolve is how a woman known to wander constantly, known to enter other residents' rooms, ended up in a male resident's bed without a brief while staff were present in the building. CNA1 responded because someone in the hallway yelled for her to come. The report does not say who yelled, or how long R14 had been in R80's room before that moment.

By the time inspectors returned to observe R14 in August 2025, she was in the main dining room eating lunch. No concerns were noted.

The deficiency was cited under F0600, which covers the right of residents to be free from abuse, neglect, and exploitation. Inspectors assessed the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. The complaint-based inspection was completed August 21, 2025.

For Tattnall Healthcare Center, the finding is part of a public record that now documents a substantiated abuse incident involving a cognitively impaired woman who wandered into a male resident's room, removed her own clothing, and was found there by a staff member who had to lift her out of another resident's bed. The facility's own investigation reached that conclusion. Federal inspectors confirmed it.

R14 showed no signs of distress when the Social Services Director checked on her afterward. She was lying in her bed, talking calmly, randomly. What she understood about what had happened to her that evening is not recorded anywhere in the inspection report.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Tattnall Healthcare Center from 2025-08-21 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Tattnall Healthcare Center
• Browse all GA nursing home inspections