Douglasville Center: Broken Femur Left Untreated Overnight - GA
The inspection report, filed following a complaint investigation at Douglasville Center for Nursing and Healing LLC, documents what happened to the resident identified as R1 after her fall in August 2025. Federal inspectors rated the violation as causing actual harm.
The facility received two X-rays. The first showed no fractures but had not imaged the femur. The second, which did image the femur, arrived by fax on August 24, 2025, at 2:37 p.m. It showed a displaced fracture. A nurse practitioner's signature was on the fax with instructions to send R1 out.
Nobody sent her out.
LPN AA, according to RN BB, had been making calls to the physician and nurse practitioner throughout the day and getting no reply. RN BB told inspectors she found both X-rays in the chart. She knew the second one showed the displaced femur fracture. She knew the note said to send R1 to the hospital.
R1 remained at the facility through the night.
Nurse Practitioner DD told inspectors she was not in the building on August 24. She said she had been notified when the fall occurred, ordered the X-rays, and told the nurse to contact the on-call physician because she herself was not on call. Then, according to her own account, she reviewed the X-ray report the following morning, August 25, and backdated her review to August 24.
She assessed R1 on the morning of August 25. R1 was in excruciating pain. NP DD sent her to the hospital that Monday morning, roughly 18 or more hours after the fax confirming the broken femur had arrived.
The facility's own medical director told inspectors his standard was unambiguous. In a phone interview on October 29, he said that when a resident had pain and tenderness following a fall, he expected that resident to be sent out immediately if injured. He did not describe the delay as acceptable. He described it as the opposite of what should have happened.
A displaced femur fracture is among the more serious injuries a nursing home resident can sustain. The femur is the longest and strongest bone in the body. Displacement means the broken ends have shifted out of alignment, which causes severe pain and, without prompt intervention, carries risks of blood loss, nerve damage, and complications that worsen with time.
The inspection report does not describe what condition R1 was in when she arrived at the hospital, what treatment she required, or what the delay cost her beyond the hours she spent in pain.
What it does describe is a breakdown at nearly every level of the facility's response. The nurse making calls could not reach anyone with authority to act. The nurse practitioner who left instructions on the fax was not reachable by phone and did not follow up until the next morning. The on-call physician, who NP DD said should have been contacted, does not appear in the report as having responded at all. The X-ray results sat in the chart.
The medical director's stated expectation, that a resident in pain after a fall should be sent out immediately, was not met. His own facility did not meet it.
Inspectors cited the violation under F0684, the federal standard requiring that a facility provide care and services that attain or maintain the highest practicable well-being of each resident. The citation level was actual harm, meaning inspectors determined R1 was hurt, not just placed at risk.
The complaint inspection was conducted on October 29 and 30, 2025, more than two months after the night R1 spent with a broken femur, waiting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Douglasville Center For Nursing and Healing LLC from 2025-10-30 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 6, 2026 · Our methodology
Douglasville Center for Nursing and Healing LLC in Douglasville, GA was cited for violations during a health inspection on October 30, 2025.
Federal inspectors rated the violation as causing actual harm.
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.