Hazelhurst Court Care And Rehabilitation Center
Hazelhurst Court Care and Rehabilitation Center in HAZLEHURST, GA — inspection on September 26, 2025.
Found 3 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
jeopardy to resident health or safety
they were a Do Not Resuscitate (DNR).
The DON stated that R1's death occurred during the shift change (7:00 am-7:00 pm nursing staff going off shift and 7:00 pm-7:00 am nursing staff coming on shift).
Cross-reference to F-F678
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Hazelhurst Court Care and Rehabilitation Center
180 Burkett Ferry Road Hazlehurst, GA 31539
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on [DATE] at 3:09 pm, LPN BB confirmed she worked on [DATE].
She stated that she had last checked on R1 when she gave R1 her evening medications, that R1 was a little more tired at that time, but alert and accepted her medications.
When LPN BB was questioned about how she became aware that R1 had passed away, LPN BB stated she found out after the fact (on [DATE], while still at the facility); one of the nurses came to the nurses' station, and she overheard them talking about it. LPN BB stated that around 6:30 pm (on [DATE]), she had already counted (controlled) medications with the on-coming night shift nurse (LPN HH) and handed her the (medication cart) keys.
When LPN BB was questioned about whether CNA AA had asked for assistance in R1's room prior to it becoming known that R1 had passed, LPN BB stated that CNA AA had stepped out in the hall and asked who the nurse was for R1. LPN BB stated that CNA AA was told by LPN CC (the other day shift nurse working with LPN BB on [DATE]) that LPN HH (on-coming night shift nurse) had taken over.
During an interview on [DATE] at 10:58 am, CNA AA confirmed she worked the day shift (7:00 am-7:00 pm) on [DATE] and was assigned to R1.
CNA AA stated that around supper time, she went into R1's room; she had already been in there before to reposition her for supper and get her upright (in bed).
She went back into R1's room and offered to help R1 with her supper, but R1 told her no and said she was not feeling well. CNA AA stated R1 felt cold, so she went and told LPN BB about it and that R1 did not want to eat. CNA AA stated she continued to pass out supper trays.
When she came back around to check on R1 again, it was around 6-something, and R1 was cold. CNA AA stated she stepped to the door (of R1's room) and said she needed help, and the nurses came down. CNA AA confirmed that CNA FF also came into R1's room and then told the nurses.
During an interview on [DATE] at 1:38 pm, LPN HH stated that on [DATE], she had come in to work and gotten a report from the day shift nurse (LPN BB).
They counted the (medication) carts, and she (LPN HH) took the keys. LPN HH stated that she then stepped outside to chat with her boss.
While outside, CNA FF came outside and told her that R1 had passed away. LPN HH stated that she then came back inside and went to R1's room. R1 had no respirations and no pulse, and her eyes were fixed and dilated. LPN HH confirmed she did not look at R1's code status herself, nor did any of the other nurses who were there.
During an interview on [DATE] at 7:43 am, CNA FF (who worked the [DATE] night shift 7:00 pm-7:00 am) stated she was alerted to something being wrong by CNA AA, who had come to R1's door and called out the resident's name twice. CNA FF said she could tell something was wrong by the tone of CNA AA's voice.
CNA FF stated she went and told the nurses at the nursing station (LPN BB and LPN CC) that R1 was deceased . CNA FF stated that LPN BB responded that she was not in charge anymore, to go get LPN HH, and LPN CC backed LPN BB up and said they had already turned in the keys.
Neither nurse went to R1's room. CNA FF went looking for LPN HH and located her outside, and let her know that R1 was deceased and LPN HH came inside.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Hazelhurst Court Care and Rehabilitation Center
180 Burkett Ferry Road Hazlehurst, GA 31539
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited HAZELHURST COURT CARE AND REHABILITATION CENTER in HAZLEHURST, GA for a deficiency under regulatory tag F-F0835 during a complaint investigation conducted on 2025-09-26.
Category: Administration Deficiencies
The facility was found deficient in the following area: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 3 deficiencies cited during this inspection of HAZELHURST COURT CARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-15.