Fayetteville Center: Unsafe Discharge Violations - GA
The resident, identified as R7 in inspection records, fell during the overnight shift of July 14-15, 2025. Licensed Practical Nurse III was working that shift from 8:01 p.m. to 7:24 a.m.
Federal law requires nursing homes to immediately notify families when residents experience accidents or injuries. The facility's own policy, revised in January 2024, states staff must "promptly inform" residents and notify family members when accidents occur.
But R7's family never received that call.
The facility created documentation claiming otherwise. An SBAR communication form, dated July 15 but created at 3:41 a.m. on July 16, stated that the family was notified at 6:50 a.m. on July 15, and the primary care physician was notified at 11:00 a.m. the same day.
When inspectors contacted R7's family member, who serves as the responsible party, the truth emerged. During a telephone interview on August 27, 2025, the family member stated they never received a call at 6:50 a.m. on July 15 about the fall.
LPN III confirmed this during her own interview with inspectors on September 3. She admitted she did not call the family before leaving work regarding R7's fall. Instead, she said she notified a medical service that takes calls from the facility after 5 p.m. and on weekends.
The deception deepened during the day shift handoff.
Licensed Practical Nurse JJJ received report from LPN III on July 15. During an interview on September 23, LPN JJJ told inspectors that LPN III never mentioned R7's fall during the shift change report.
The family was visiting that day. They asked LPN JJJ directly if their father had fallen the night before.
LPN JJJ immediately called LPN III to ask about the fall. LPN III initially told her that R7 did not fall.
Only after LPN JJJ pressed further did LPN III admit that R7 had indeed fallen.
LPN JJJ then assessed the resident and notified the nurse practitioner about the fall, receiving an order for X-rays.
R7 had been admitted to the facility with significant medical conditions, including bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. His admission record shows these diagnoses put him at particular risk for complications from falls.
The facility's Director of Nursing was unable to verify key details of the incident. During an interview on September 24, she told inspectors she could not confirm that the physician or medical service was actually notified of R7's fall on the morning of July 15, 2025, despite the facility's documentation claiming notification occurred at 11:00 a.m.
The pattern reveals a breakdown in basic communication protocols. The overnight nurse failed to notify the family as required by federal regulations and facility policy. She failed to inform the day shift nurse about the fall during handoff. When questioned directly, she initially lied to a colleague about whether the fall had occurred.
The family discovered their father's fall only because they happened to visit and asked the right questions. Had they not been present that day, or had they not directly asked about a fall, the incident might have remained hidden from them entirely.
Federal inspectors found that the facility's own documentation was unreliable. The SBAR form claiming family notification occurred was created nearly a full day after the supposed notification call. The Director of Nursing could not verify that medical professionals were actually contacted as documented.
This case illustrates how notification failures can cascade through multiple levels of care. The overnight nurse's initial failure to follow protocol led to false documentation, deceptive communication with colleagues, and a family left uninformed about their loved one's medical emergency.
R7's case was one of seven residents reviewed by inspectors for notification compliance. The facility failed to properly notify families and physicians in this case, violating federal regulations designed to ensure families can participate in care decisions and respond quickly to medical emergencies.
The inspection occurred on November 19, 2025, following a complaint. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
For families of nursing home residents, the case highlights the importance of asking direct questions during visits and not assuming that facilities will proactively share critical information about accidents or medical incidents, even when federal law requires such notification.
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.
The resident, identified as R7 in inspection records, fell during the overnight shift of July 14-15, 2025.
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.