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
Findings included:A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE] and had diagnoses that included cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. A review of R1's clinical record revealed a [DATE] Advanced Directive physician's order.
The physician's order specified that R1 was a Full Code and to attempt CPR.A review of R1's care plan revealed a [DATE] Advanced Directive care plan that documented R1 was a Full Code.
The care plan included an intervention, dated [DATE], to attempt resuscitation (CPR). A review of the Facility Notification of Hospice Admission/Change form revealed that R1 was admitted to hospice services on [DATE].
The admitting diagnosis was cerebral atherosclerosis.
Further review of R1's care plan revealed an [DATE] care plan which R1 was under the care of hospice services.
Following R1's admission to hospice services, an updated Physician Orders for Life Sustaining Treatment (POLST) form, dated [DATE], was completed.
The POLST form specifies attempting CPR.
Therefore, R1 remained a Full Code.
During an interview on [DATE] at 4:11 pm, Registered Nurse (RN) Unit Manager GG confirmed that R1's Responsible Party wanted R1's Advanced Directives to remain a full code status. A review of progress notes revealed a [DATE] 6:55 pm nurse's note entry by Licensed Practical Nurse (LPN) HH, that staff alerted her that R1 was deceased . A subsequent nurse's note entry on [DATE] at 7:00 pm documented that R1 was assessed and noted to have no pulse or respirations, and skin was cool to the touch.
The note further documented that the Director of Nursing, Administrator, RN unit manager, Nurse Practitioner, and hospice nurse were notified. A review of hospice documentation revealed a [DATE] Visit Note Report that documented the hospice RN pronounced R1's death on [DATE] at 7:31 pm.
However, there was no evidence that facility nursing staff attempted CPR on R1 when she was noted to have no pulse or respirations, as specified in her Advanced Directives care plan.
During an interview on [DATE] at 1:52 pm, the DON confirmed that CPR was not attempted on R1 on [DATE].
She stated that R1 was fairly new, being on hospice services, and what she gathered through interviews was that the night and day shift nurses thought that once a resident was receiving hospice services, 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
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.
115626 09/26/2025
Hazelhurst Court Care and Rehabilitation Center 180 Burkett Ferry Road Hazlehurst, GA 31539
received a phone call from LPN HH, letting her know that R1 had been a Full Code.Cross-reference to
jeopardy to resident health or safety
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.