Fayetteville Center: Care Plan Failures - GA
The violation occurred at Fayetteville Center for Nursing & Healing on July 15, 2025, when Licensed Practical Nurse III worked an overnight shift from 8:01 pm to 7:24 am. Federal inspectors found the facility violated requirements to immediately notify families of accidents affecting residents.
The resident, identified as R7 in inspection records, was admitted to the facility with bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. He fell during LPN III's shift on the night of July 14-15.
A facility communication form documented that the family was supposedly notified at 6:50 am on July 15 and the primary care physician at 11:00 am. But when inspectors interviewed the resident's family member, who serves as the responsible party, they revealed they never received any call about the fall.
"The family stated they did not receive a call at 6:50 am on July 15, 2025, from the facility stating that R7 had a fall," inspectors wrote.
When questioned directly, LPN III admitted she never called the family before leaving work that morning. She told inspectors she only notified a medical service that handles after-hours calls for the facility.
The deception deepened during the day shift handoff. Licensed Practical Nurse JJJ, who received the morning report from LPN III, said her colleague never mentioned that any resident had fallen during the overnight shift.
The truth emerged only when the family arrived for a visit and asked pointed questions.
"The family was visiting and asked if their dad had a fall last night," LPN JJJ told inspectors during a September interview.
LPN JJJ immediately called her colleague to clarify. Initially, LPN III maintained the lie.
"LPN JJJ stated she immediately called LPN III and was initially told that R7 did not fall," the inspection report states.
Only after further conversation did LPN III finally admit the resident had fallen during her shift.
LPN JJJ then assessed the resident and contacted the nurse practitioner, who ordered X-rays. But the family had already been left in the dark for hours about their father's accident.
The facility's own policy, reviewed and revised in January 2024, explicitly requires prompt notification of families when accidents occur. The policy states its purpose is "to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification."
Accidents are specifically listed among circumstances requiring immediate notification.
Federal regulations mandate that nursing homes immediately tell residents, their doctors, and family members about situations that affect the resident, including injuries and accidents. The requirement exists to ensure families can make informed decisions about their loved one's care and safety.
When inspectors interviewed the Director of Nursing on September 24, she could not verify that the physician or medical service had actually been notified about the fall on the morning of July 15, despite the documentation claiming otherwise.
The inspection was conducted in response to a complaint. Inspectors reviewed seven residents' records for notification compliance and found that this was the only case where proper notification failed to occur.
The facility's communication breakdown created a cascade of problems. The overnight nurse failed to notify the family, lied to her replacement, and may not have properly notified medical personnel as documented. The family discovered their father's fall only through their own questions during a visit, not through the facility's required notification.
LPN III's initial denial when questioned by her colleague suggests an attempt to cover up the notification failure. Only when pressed further did she acknowledge the truth about the resident's fall.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. But for the family involved, the failure represented a significant breach of trust and transparency about their father's safety and medical condition.
Federal inspectors noted that the facility must have safeguards to ensure immediate notification of changes in residents' conditions. The failure in this case demonstrates gaps in both the execution of notification requirements and the honesty of staff when questioned about critical incidents.
The resident's complex medical history, including previous brain injury from intracerebral hemorrhage and bilateral shoulder injuries, made prompt notification of any new fall particularly important for assessing potential complications or the need for immediate medical intervention.
Instead, the family learned about their father's accident through their own inquiry during a routine visit, discovering that facility staff had failed to follow both federal regulations and their own written policies for protecting resident safety and family communication.
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 violated requirements to immediately notify families of accidents affecting residents.
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.