Macon Rehab: Resident Died After Head Injury at Dialysis - GA
The resident, identified in inspection records only as R1, was at a dialysis clinic when staff noticed blood. A dialysis worker, identified in the report as staff member AA, described the wound as a straight line on the back of R1's head, like a scrape that had reopened. He applied pressure immediately and called an ambulance.
R1 arrived at the emergency room at 7:45 in the morning. A CT scan showed a subarachnoid hemorrhage, a type of bleeding that occurs in the space surrounding the brain. He died that same day at 12:25 in the afternoon. The Georgia death certificate listed the immediate cause of death as cardiac arrest due to respiratory failure and renal failure. A coroner's death investigation report noted the subarachnoid hemorrhage on discharge.
By evening, the administrator at Macon Rehabilitation and Healthcare had been notified. The coroner called her personally and told her not only that R1 had died, but that he had a hematoma and a subarachnoid hemorrhage.
What happened next is the story the inspection report tells.
The administrator said she tried to call the dialysis clinic. The phone rang and rang. She left a voicemail. The clinic never called back. She did not go to the clinic in person to speak with management. She did not send anyone else. She did not follow up beyond that single unanswered call.
Instead, she said, she spoke at some point with an investigator, who told her she would handle talking to the dialysis clinic staff. The administrator said she handed the investigation over to her. The investigator never got back in touch.
Weeks passed. The administrator eventually called the Sheriff's Office to obtain a copy of the investigator's report and was told she would have to come to the office to pick it up in person. The inspection report does not indicate she did.
That is the full account of Macon Rehabilitation and Healthcare's investigation into the death of a resident who arrived at dialysis alive and left by ambulance with bleeding on his brain.
The dialysis clinic's response was no more forthcoming. When inspectors contacted the clinic, the clinic manager said she would need to speak with her legal team before providing statements from the nurses and patients who were present during the incident. The inspection report does not indicate those statements were ever provided.
Federal inspectors cited the facility under F0610, the regulation requiring nursing homes to investigate and report allegations of abuse, neglect, and injuries of unknown origin. The citation was rated at minimal harm or potential for actual harm, affecting few residents. That rating reflects the regulatory tier, not the outcome for R1, who did not survive.
The gap between those two things, the regulatory language and what actually happened to a person, is worth sitting with. A man bled from a wound on the back of his head while receiving medical treatment away from the facility that was supposed to oversee his care. He died of a brain hemorrhage the same morning. And the investigation his nursing home conducted consisted of one unreturned voicemail and a decision to wait for someone else to do the work.
Subarachnoid hemorrhages are not subtle events. Blood in the subarachnoid space puts pressure on the brain. The condition can cause rapid deterioration and death. Whether the hemorrhage was caused by the head wound, whether the wound itself was caused by a fall or some other incident at the clinic, and whether anything at the dialysis facility contributed to R1's death, those questions are exactly what an investigation is supposed to answer.
Macon Rehabilitation and Healthcare did not answer them.
The inspection report does not say whether R1 had family members who were notified of the circumstances of his final hours. It does not say whether anyone at the nursing home ever explained to them that their relative arrived at dialysis and left by ambulance with a head wound and bleeding on his brain. It does not say whether anyone at the facility knows, even now, exactly what happened inside that clinic.
What the report does say is that the administrator was told by the coroner himself, on the night R1 died, that there was a hematoma and a subarachnoid hemorrhage. She had that information. She had the name of a clinic where witnesses were present. She had a staff member, identified only as AA, who had been there, applied pressure to the wound, and called the ambulance himself.
She left a voicemail.
The dialysis clinic manager's response, that she would consult her legal team before allowing staff to speak, is its own answer of a kind. Legal teams are consulted when liability is a concern. Liability is a concern when something went wrong. The clinic manager's instinct, whatever it reflects about what happened inside that clinic, did not make the nursing home's job easier. But it also did not make the nursing home's obligation disappear.
The inspection report covers three pages. The narrative available for this article is drawn from the final page and portions of what preceded it. The full account of how R1 came to have a wound on the back of his head, and what the dialysis clinic's own records show about the incident, is not contained in the portion of the report available here.
What is contained in the report is enough to see the shape of what failed.
A resident in a nursing home is transported off-site for a medical procedure. Something happens. He ends up in an ambulance. He dies within hours. The nursing home learns that same evening that he suffered a brain hemorrhage. And in the days and weeks that follow, the facility's investigation produces no witness statements, no visit to the clinic, no written account of events, and no report in hand.
The administrator told inspectors she called the Sheriff's Office to get the investigator's report and was told she'd have to come pick it up herself. The inspection report ends there. Whether she ever made that drive, whether she ever read that report, whether she ever learned what happened to R1 in the hours before he died, the record does not say.
R1 died on the same day he arrived at the emergency room, a few hours after dialysis staff pressed a cloth to the back of his head and waited for an ambulance. The nursing home that was responsible for his care is still waiting for a phone call back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Macon Rehabilitation and Healthcare from 2025-09-02 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 30, 2026 · Our methodology
MACON REHABILITATION AND HEALTHCARE in MACON, GA was cited for violations during a health inspection on September 2, 2025.
The resident, identified in inspection records only as R1, was at a dialysis clinic when staff noticed blood.
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.