Fayetteville Center For Nursing & Healing Llc
FAYETTEVILLE CENTER FOR NURSING & HEALING LLC in FAYETTEVILLE, GA — inspection on November 19, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] with diagnoses of, but not limited to, bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage.
Review of the admission Minimum Data Set (MDS) for R7, dated 6/24/2025, revealed a Brief Interview for Mental Status (BIMS) was not assessed.
Review of the Employee Punch Report revealed LPN III worked the following hours on 7/14/2025 8:01 pm to 7/15/2025 7:24 am.
Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 7/15/2025, created on 7/16/2025 at 3:41 am, revealed that R7 had a fall.
The SBAR documented that the family was notified on 7/15/2025 at 6:50 am, and the primary care physician was notified on 7/15/2025 at 11:00 am. A telephone interview on August 27, 2025, at 2:13 pm with R7's family member, who is the RP, revealed that 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. A telephone interview on 9/3/2025 at 12:40 pm with Licensed Practical Nurse (LPN) III stated she did not call the family prior to leaving work regarding R7's fall on 7/15/2025.
She stated she notified __ (the medical service that takes calls from the facility after 5 pm or weekends) of R7's fall prior to leaving work on the morning of 7/15/2025. An interview on 9/23/2025 at 1:44 pm with LPN JJJ stated she received report from LPN III on 7/15/2025.
She stated LPN III never mentioned that R7 had a fall on the 7 pm to 7 am shift. LPN JJJ stated the family was visiting and asked if their dad had a fall last night. LPN JJJ immediately called LPN III and was initially told that R7 did not fall. LPN JJJ stated that after having a further conversation with LPN III, she admitted that R7 had a fall.
Licensed Practical Nurse JJJ stated she assessed the resident and notified the Nurse Practitioner of the fall and received an order for x-rays. An interview on 9/24/2025 at 9:23 am with the Director of Nursing stated she was not able to verify that the physician/medical service was notified of R7's fall on the morning of 7/15/2025.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fayetteville Center for Nursing & Healing LLC
110 Brandywine Boulevard Fayetteville, GA 30214
SUMMARY STATEMENT OF DEFICIENCIES
9/4/2025 at 2:45 pm, R8's family member, who is the RP, stated that on 8/1/2025, it was reported to the ADON and a Certified Nursing Assistant (CNA) that R8's shorts and eyeglasses were missing.
The family member stated the CNA returned with R8's shorts, but the glasses could not be located.
She stated she reported the missing items again in a formal email on 8/3/2025. In an interview on 9/9/2025 at 11:10 am, the ADON stated she never had any communication with the family of R8 regarding lost eyeglasses or clothes.
She stated that if a resident or family reported lost items, she would report it to the Social Worker.
The ADON stated the Social Worker was responsible for logging the resident/family grievances into the __ system.
The ADON stated she would also report the lost items to the laundry department so that they could look for the missing items. In an interview on 9/16/2025 at 10:57 am, the ADON confirmed that she did receive an email from R8's family.
She stated she does not remember reading the email.
She stated, Those things are handled by the DON.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fayetteville Center for Nursing & Healing LLC
110 Brandywine Boulevard Fayetteville, GA 30214
SUMMARY STATEMENT OF DEFICIENCIES
Review of the admission Record for R16 revealed she was admitted to the facility on [DATE] and a diagnosis of, but not limited to, dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy.
Review of the resident's admission MDS dated [DATE] revealed a BIMS assessed at eight, indicating moderately impaired.
Section GG revealed that R16 requires partial/moderate assistance with transfer.
Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS.
Review of the care plan initiated 7/25/2025 revealed that R16 has an ADL self-care performance deficit related to limited mobility.
Intervention to be implemented included a mechanical lift with two staff for assistance with transfers.
Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred R16 from bed to wheelchair causing a laceration on right leg.
The investigation revealed that as a result of CNA EEEE failure to follow the facility policy of using a mechanical lift when transferring R16 causing a small laceration to R16's great right toe.
Review of the CNA EEEE employee file in the presence of the Human Resource Director revealed: a Disciplinary Action Form description of violation and events leading to personnel action: employee fail to use lift to transfer resident from bed to the wheelchair.
Work improvement plan: Employee must perform all job duties outlined in the description as requested by manager/supervisor.
Signed by the employee, UM, and the DON dated 9/8/2025.
Further review revealed a Separation Notice with a hire date of 9/1/2019 and a termination date of 9/9/2025 for violating company policies; poor performance; transferred resident without using lift as educated, signed by Human Resources on 9/10/2025. A telephone interview on 9/17/2025 at 10:24 am with CNA EEEE stated she was educated on reviewing the kiosk for the residents' plan of care for transfers.
The CNA stated R16 was assigned to her on 9/8/2025.
She also stated she was aware that R16 required a transfer with two people using the mechanical lift.
The CNA stated R16 had been crying and complained of general hurting and refused to get out of bed for the day.
She stated R16 did not want to get up using the mechanical lift to be transferred from the bed to the chair.
The CNA stated she asked R16 was it okay for her (CNA) to be transferred from the bed into the chair.
The CNA stated the resident agreed and was transferred from the bed to the wheelchair.
The CNA stated she did not report to the charge nurse or the UM that the resident was in pain and did not want to get up.
The CNA stated she was not aware that R16 sustained an injury to the right knee and toe during the transfer. An interview on 9/17/2025 at 10:32 with UM LLL stated she has daily huddles with the staff on 100-700 hall.
She stated that because of the incident with R7, she educates the staff to review the resident's plan of care.
All mechanical lifts must be done with two staff; in the event there is not a second person available she (UM) will assist with the transfer.
The UM stated on 9/8/2025, R16's family approached her and asked, Why was my mom transferred out of bed today without using the mechanical lift? The family went on to inform the UM that R16 was in pain, and her knee had been injured during the transfer.
She stated the resident was assessed and sent to the hospital.
The UM stated she asked the CNA assigned to R16 did you transfer R16 without using the mechanical lift.
The CNA confirmed she had transferred the resident from the bed to the wheelchair alone without the lift.
She stated she reported the incident to the Administrator immediately, and the CNA was sent home by the Assistant Director of Nursing.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fayetteville Center for Nursing & Healing LLC
110 Brandywine Boulevard Fayetteville, GA 30214
SUMMARY STATEMENT OF DEFICIENCIES
family did meet with the Administrator, DON, and the Clinical Marketing Director on 8/1/2025.
The family stated that the Clinical Marketing Director informed the family that it was her decision that R7 was not allowed to return.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fayetteville Center for Nursing & Healing LLC
110 Brandywine Boulevard Fayetteville, GA 30214
SUMMARY STATEMENT OF DEFICIENCIES
chair.
The resident agreed and was transferred from the bed to the wheelchair.
The CNA stated she was not aware R16 sustained an injury to the right toe due to the transfer. An interview on 9/9/2025 at 9:30 am with the Administrator stated his expectations that all documentation is completed after a fall and or incident. He stated that documentation includes updating the residents' care plan.
Cross reference F-F689
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fayetteville Center for Nursing & Healing LLC
110 Brandywine Boulevard Fayetteville, GA 30214
SUMMARY STATEMENT OF DEFICIENCIES
Review of the admission Record for R16 revealed a diagnosis of, but not limited to, dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy.
Review of the resident's admission MDS dated [DATE] revealed a BIMS assessed at eight, indicating moderately impaired.
Section GG revealed R16 is partial/moderate assistance with transfer.
Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS.
Review of the care plan initiated 7/25/2025 revealed that R16 has an ADL self-care performance deficit related to limited mobility.
Intervention to be implemented included a mechanical lift with two staff assistance for transfers.
Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred R16 from bed to wheelchair causing laceration on the right leg.
The investigation revealed that as a result of CNA EEEE's failure to follow the facility policy of using a mechanical lift when transferring R16, a small laceration to R16's great right toe. A telephone interview on 9/21/2025 at 4:37 pm with R16's family stated that on 9/8/2025, while visiting mom, she (R16) verbalized that her knee was hurting.
She stated she was informed by B that a CNA had transferred mom without using the mechanical lift.
She stated she was told that her mom's right leg/foot was injured.
She stated she immediately reported the incident to the Unit Manager. A phone interview on 9/19/2025 at 2:58 pm with the facility's Medical Director (MD) stated he was part of the Quality Assurance and Performance Improvement Meeting and discussed and reviewed the safe transfers policies. He stated that during the meeting, the team discussed educating the staff to report incidents as they happen and accurately.
The MD stated he was not aware that another incident with failing to use the mechanical lift had occurred.
The MD was informed on 9/8/2025 that R16 was transferred without the mechanical lift and sustained an injury to her right great toe.
The MD stated he would follow up with the Administrator and the other Health Care Providers regarding R16's unsafe transfer on 9/8/2025.
Cross-reference to F-F600
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fayetteville Center for Nursing & Healing LLC
110 Brandywine Boulevard Fayetteville, GA 30214
SUMMARY STATEMENT OF DEFICIENCIES
(NP) in the clinical meeting as the orders were reviewed and adjustments could be made by the NP at that time.
She stated that after hours and on weekends, the nurse reviewed the hospital orders with the after-hours medical service.
The DON stated she was not aware that R8's CPAP and oxygen were not part of the order summary.
The DON stated she would review the resident's chart.In an interview on 9/10/2025 at 9:50 am, the DON stated R8 did use oxygen and had a CPAP machine, and there was no order.
She stated that the nurses would be educated to ensure that the hospital orders were accurately transcribed.
Facility ID: