Taylor County Health & Rehab: Fall Injury Citation GA
BUTLER, GA - Federal inspectors cited Taylor County Health and Rehabilitation for safety violations after a resident suffered a closed head injury and laceration when staff failed to follow established care protocols during a bed bath.
Critical Safety Breach During Personal Care
The most serious violation occurred when a certified nursing assistant conducted a bed bath for a resident who required two-person assistance according to her care plan. The resident, identified as R52, had been assessed as needing extensive assistance due to hemiplegia and hemiparesis following a stroke, along with abnormalities of gait and mobility and muscle weakness.
During the April 28, 2024 incident, the nursing assistant was providing care alone when the resident fell from her bed, sustaining a one-inch laceration to her forehead and a closed head injury. The resident required emergency department treatment for these injuries.
The resident told investigators that "it did not help that there was no sheet on her bed, and the mattress was slippery without it" and confirmed that "they always use two nurse aides to give me a bed bath."
The nursing assistant acknowledged during the investigation that she should have had additional help but stated she was "just trying to get done." Multiple staff members confirmed that two-person assistance was the standard protocol for this resident's care due to her limited arm function and weakness.
Medical Significance of Care Plan Deviations
When residents require two-person assistance for personal care activities, this assessment reflects significant functional limitations that create fall risks. Residents with hemiplegia have paralysis on one side of their body, making it difficult to maintain balance or catch themselves during transfers or position changes.
During bed baths, residents must be repositioned multiple times, which can cause disorientation, dizziness, or loss of balance. The two-person requirement serves multiple safety functions: one caregiver can maintain physical support and stability while the other performs the bathing tasks, ensuring continuous safety monitoring throughout the procedure.
The facility's own comprehensive nursing assessment had identified that staff needed to complete all tasks related to the resident's positioning and transfers. This assessment specifically triggered a care plan notation requiring "two people assist with transfers," making the single-caregiver approach a clear deviation from established protocols.
Widespread Hand Hygiene Failures During Medication Administration
Federal inspectors identified systematic infection control violations during medication administration rounds. A licensed practical nurse was observed failing to perform proper hand hygiene between residents while administering medications to four different residents.
The violations included administering eye drops, narcotic pain medications, and crushed medications mixed with food without washing hands or using alcohol-based hand sanitizer between residents. In each case, the nurse handled medication cups, touched surfaces in residents' rooms, and moved directly to the next resident without following infection control protocols.
During one observation, the nurse administered a tramadol tablet to a resident, handled the water cup the resident had used, placed it on the bedside table, and proceeded directly to prepare medication for the next resident without any hand hygiene.
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
TAYLOR COUNTY HEALTH AND REHABILITATION in BUTLER, GA was cited for violations during a health inspection on August 28, 2024.
The resident required emergency department treatment for these injuries.
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.