Hazelhurst Court Care: Resident Died Alone - GA
The resident, identified in federal inspection records only as R1, was already dead.
CNA AA had been assigned to R1 for the full day shift on the date of the incident. Around supper time, she went to help R1 eat. R1 said she wasn't feeling well and didn't want to eat. CNA AA noticed R1 felt cold and told her nurse, LPN BB, before continuing to pass out meal trays to other residents.
When CNA AA came back to R1's room, R1 was cold again. She stepped to the doorway and called out that she needed help.
CNA FF, who had just arrived for the night shift, heard the tone of CNA AA's voice and understood something was wrong. She went to the nurses' station and told LPN BB and LPN CC that R1 was deceased.
LPN BB said she was not in charge anymore. LPN CC backed her up. They had already counted the controlled medications and turned in the keys to the incoming night nurse, LPN HH. Neither nurse went to R1's room.
CNA FF went looking for LPN HH and found her outside, chatting with her supervisor. She told LPN HH that R1 had passed. LPN HH came inside, went to R1's room, and confirmed no respirations, no pulse, eyes fixed and dilated.
LPN HH later told inspectors she had not checked R1's code status herself. Neither had any of the other nurses present.
LPN BB told inspectors she had last seen R1 alive when she gave her evening medications, describing her as "a little more tired" but alert. She said she found out R1 had died after the fact, when she overheard nurses talking at the station.
Federal inspectors cited the deficiency at the immediate jeopardy level, the most serious classification available under Medicare and Medicaid oversight. The inspection was completed September 26, 2025.
R1 spent her final hours in a facility where the nurses responsible for her care decided, in the moment it mattered, that the shift change had already happened.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
Hazelhurst Court Care and Rehabilitation Center in HAZLEHURST, GA was cited for violations during a health inspection on September 26, 2025.
The resident, identified in federal inspection records only as R1, was already dead.
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.