Hazelhurst Court: No CPR for Full Code Resident - GA
Her records said Full Code.
Federal inspectors who reviewed the case found that the facility had failed to carry out the woman's own Advanced Directive, a legally binding document specifying exactly what she wanted done if her heart stopped. The failure triggered an Immediate Jeopardy citation, the most serious classification available to federal inspectors, reserved for situations where noncompliance has caused or had the likelihood to cause serious injury, harm, impairment, or death.
The resident, identified in inspection records only as R1, had been a patient at the facility and carried a list of diagnoses that included cerebral atherosclerosis, dysphagia, gastroesophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. Her physician had entered an order specifying she was a Full Code and that staff should attempt CPR if needed. Her care plan, reviewed by inspectors, contained the same instruction, with an explicit intervention directing staff to attempt resuscitation. The care plan had been in place and was current.
At some point before her death, R1 was admitted to hospice services. The admitting diagnosis was cerebral atherosclerosis. Her care plan was updated to reflect that she was receiving hospice care. But critically, her code status was not changed. A Physician Orders for Life Sustaining Treatment form, known as a POLST, was completed after her hospice admission. That form also specified that CPR should be attempted. R1 remained a Full Code in every document that governed her care.
The RN Unit Manager confirmed this directly to inspectors during an interview. R1's responsible party, the family member or designee authorized to speak on her behalf, wanted her Advanced Directives to remain in place. Full Code. Attempt CPR. That was the instruction, documented, signed, and sitting in her chart.
She was found deceased during a shift change.
A nurse's note entered at 6:55 p.m. recorded that staff had alerted the on-duty Licensed Practical Nurse that R1 was deceased. Five minutes later, at 7:00 p.m., a follow-up note documented that R1 had been assessed and found to have no pulse or respirations, with skin cool to the touch. The Director of Nursing, the Administrator, the RN Unit Manager, a Nurse Practitioner, and the hospice nurse were all notified. A hospice Visit Note Report later recorded that the hospice RN pronounced R1's death at 7:31 p.m.
There was no documentation anywhere in the record that facility nursing staff had attempted CPR.
The Director of Nursing confirmed it plainly when inspectors interviewed her. CPR was not attempted. Her explanation was that R1 was fairly new to hospice services, and what she had gathered through her own internal interviews was that nurses on both the outgoing and incoming shifts had assumed that a hospice admission automatically meant Do Not Resuscitate. The shift change itself, the handoff moment between the 7:00 a.m. to 7:00 p.m. crew going off duty and the 7:00 p.m. to 7:00 a.m. crew coming on, was when R1 was found. Two sets of nurses. The same assumption between them.
That assumption was wrong, and it was contradicted by every document in R1's chart.
The conflation of hospice care with DNR status is a misunderstanding with potentially fatal consequences, and it is not uncommon. Hospice is a philosophy of care focused on comfort rather than curative treatment, but it does not automatically strip a patient of their code status. A patient can be enrolled in hospice and still be a Full Code. The two are not mutually exclusive, and the decision belongs to the patient and their family, not to a nurse making a shift-change assumption. R1's family had made that decision clearly. They wanted CPR attempted. The POLST form said so. The care plan said so. The physician's order said so.
Nobody attempted it.
The inspection, conducted as a complaint investigation, covered a sample of 11 residents. The failure was identified in one of them. But the Director of Nursing's account of what happened suggests the misunderstanding was not limited to a single nurse on a single shift. She described it as a shared belief between day shift nurses going off duty and night shift nurses coming on, a collective assumption that hospice meant DNR, that no one thought to verify against the chart before R1 was pronounced dead.
The facility's Administrator and Director of Nursing were notified of the Immediate Jeopardy determination at 2:15 p.m. on the day inspectors made the finding. The facility submitted a removal plan, which was accepted. Inspectors determined that the corrective actions were sufficient to remove the immediacy of the deficient practice.
What that means in practical terms is that the facility identified what went wrong, described what it would do differently, and satisfied inspectors that the immediate danger to other residents had been addressed. It does not mean the violation itself was erased. It does not mean R1 received the care her records required.
The question that the inspection report leaves unanswered is how a facility arrives at a moment where two consecutive nursing shifts, during a handoff, both operate under the same factually incorrect assumption about a resident's code status, and neither one opens the chart to confirm it before the window for intervention closes. The POLST form was there. The care plan was there. The physician's order was there. The responsible party had been clear. The RN Unit Manager knew. The documentation was not hidden or ambiguous.
R1's family had made a decision, put it in writing, had it entered as a physician's order, had it written into the care plan, and had it reaffirmed on a POLST form completed specifically after her hospice admission. They did everything the system asks families to do when they want their wishes honored.
At the shift change, when it mattered, nobody checked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hazelhurst Court Care and Rehabilitation Center from 2025-09-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 12, 2026 · Our methodology
Hazelhurst Court Care and Rehabilitation Center in HAZLEHURST, GA was cited for violations during a health inspection on September 26, 2025.
Her physician had entered an order specifying she was a Full Code and that staff should attempt CPR if needed.
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.