Hazelhurst Court Care: Immediate Jeopardy Death - GA
The other nurse on the floor backed her up.
Neither went to the room.
The resident, identified in federal inspection records only as R1, was found without respirations, without a pulse, with fixed and dilated eyes. She was dead. The nurses who had cared for her all day had already decided, at the moment a certified nursing assistant came looking for help, that the shift change had relieved them of any obligation to find out why.
Hazelhurst Court Care and Rehabilitation Center, a nursing home on Burkett Ferry Road in Hazlehurst, Georgia, was cited for an immediate jeopardy violation following a complaint inspection completed September 26, 2025. Immediate jeopardy is the most serious level of harm the Centers for Medicare and Medicaid Services can assign, reserved for situations where a facility's failures have placed residents in serious danger or, as in this case, where the failures coincided with a resident's death.
The sequence of events that inspectors documented begins earlier that evening. CNA AA, assigned to R1 for the day shift, went into the room around supper time. She had already been in once to reposition R1 and get her upright in bed. When she came back to help with the meal, R1 told her no. She was not feeling well. CNA AA noticed R1 felt cold. She went and told LPN BB, the day shift nurse assigned to R1, and then kept going down the hall to deliver the rest of the supper trays.
When CNA AA came back around to check on R1 again, it was around six in the evening. R1 was cold. She stepped to the doorway of the room and called out for help. The nurses came down.
CNA FF, who was starting the night shift, also came into the room. She could tell something was wrong by the tone of CNA AA's voice when she called out. CNA FF went to the nurses' station to tell LPN BB and LPN CC that R1 was deceased.
LPN BB told her she was not in charge anymore. Go get LPN HH. LPN CC backed her up: they had already turned in the keys.
Neither nurse went to R1's room.
CNA FF went looking for LPN HH, the incoming night nurse, and found her outside the building, chatting with her boss. CNA FF told her R1 had passed away. LPN HH came inside and went to the room. She confirmed there were no respirations, no pulse, fixed and dilated eyes.
LPN HH later told inspectors that she had not checked R1's code status herself before responding. Neither had any of the other nurses who were present.
LPN BB, interviewed by inspectors, said she had last seen R1 alive when she gave her evening medications. R1 was a little more tired than usual, she said, but alert and took her medications. LPN BB said she found out R1 had died after the fact, still on the premises, when she overheard nurses at the station talking about it. By that point, she had already counted the controlled medications with LPN HH and handed over the cart keys.
The shift change had happened. She was done.
What the record shows is a resident who told her aide she felt unwell, who felt cold to the touch, whose aide flagged the concern to a nurse and then returned to find her dead, and whose nurses, when finally told directly that she had died, responded by pointing to a medication cart handoff as the reason they did not need to go see for themselves.
CNA AA said she had reported to LPN BB that R1 felt cold and did not want to eat. LPN BB confirmed she was told. The inspection record does not indicate that LPN BB went to check on R1 after receiving that report.
The facility has not publicly responded to the findings. CMS has directed anyone seeking information on the plan of correction to contact the nursing home or the state survey agency directly.
R1 died in her room while two nurses stood at the nurses' station and one stood outside in the parking lot.
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: 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 26, 2026 · Our methodology
Hazelhurst Court Care and Rehabilitation Center in HAZLEHURST, GA was cited for immediate jeopardy violations during a health inspection on September 26, 2025.
The other nurse on the floor backed her up.
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.