Fayetteville Center: Accident Hazard Violations - GA
The incident at Fayetteville Center for Nursing & Healing involved a resident with bilateral rotator cuff injuries, cerebral infarction, and brain hemorrhage who fell on July 15, 2025. Federal inspectors found the facility failed to notify the family as required by its own policy.
Licensed Practical Nurse III worked the overnight shift from 8:01 pm July 14 to 7:24 am July 15. During that time, the resident fell.
When LPN JJJ arrived for the day shift on July 15, she received report from LPN III. "She stated LPN III never mentioned that R7 had a fall on the 7 pm to 7 am shift," according to the inspection report.
The family was visiting that day. They asked LPN JJJ if their father had fallen the night before.
LPN JJJ immediately called LPN III. "She was initially told that R7 did not fall," the report states.
But after further conversation, LPN III changed her story. "She admitted that R7 had a fall."
A facility communication form documented the fall and claimed the family was notified at 6:50 am on July 15. The form was created at 3:41 am on July 16 — more than 21 hours after the documented notification time.
When inspectors interviewed the resident's family member in August, they said they never received a call at 6:50 am about the fall.
LPN III confirmed this during her September interview with inspectors. She "stated she did not call the family prior to leaving work regarding R7's fall on 7/15/2025."
Instead, LPN III said she notified a medical service that takes after-hours calls from the facility. But the Director of Nursing told inspectors she "was not able to verify that the physician/medical service was notified of R7's fall on the morning of 7/15/2025."
The facility's own policy, revised in January 2024, requires staff to "promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification." Falls are specifically listed as circumstances requiring notification.
After learning about the fall from the family's questions, LPN JJJ assessed the resident and contacted the nurse practitioner, who ordered x-rays.
The resident had been admitted to the facility earlier in 2025. His admission assessment in June showed he had significant medical conditions including brain injuries that could affect his stability and fall risk.
The inspection found this was not an isolated communication problem. Inspectors reviewed seven residents' notification records and found the facility failed to properly notify families and physicians about this resident's fall.
The communication breakdown meant the family learned about their father's fall not from nursing staff, but by asking questions during their visit. The overnight nurse who witnessed the fall left work without making the required notifications, then initially denied the fall happened when questioned by her colleague.
LPN JJJ had to piece together what actually occurred during the previous shift through her own investigation triggered by the family's concerns. Only then did she take the required steps to assess the resident and contact medical providers.
The facility created documentation claiming notifications were made, but inspectors found those notifications never actually occurred. The family confirmed they received no call, the nurse confirmed she made no call, and the Director of Nursing could not verify that medical providers were contacted as documented.
This pattern of documenting communications that never happened raises questions about other incident reports at the facility. When staff create false records about family notifications, families lose the opportunity to make informed decisions about their loved one's care and safety.
The resident's medical conditions made fall notifications particularly important. Someone with bilateral rotator cuff injuries, stroke, and brain hemorrhage faces serious risks from falls. Prompt medical evaluation and family involvement in care decisions become critical.
Instead, the family discovered their father's fall through their own questions during a visit. The nurse who should have made notifications initially denied the fall occurred. The documentation showed notifications that never happened.
The facility's failure to follow its own notification policy left a vulnerable resident's family uninformed about a significant safety incident. They learned about the fall not through proper channels, but by asking the right questions at the right time during their visit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fayetteville Center For Nursing & Healing LLC from 2025-11-19 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 20, 2026 · Our methodology
FAYETTEVILLE CENTER FOR NURSING & HEALING LLC in FAYETTEVILLE, GA was cited for violations during a health inspection on November 19, 2025.
Federal inspectors found the facility failed to notify the family as required by its own policy.
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.