Hazelhurst Court Care And Rehabilitation Center
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Immediate jeopardy to resident health or safety
they were a Do Not Resuscitate (DNR). The DON stated that Resident 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
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hazelhurst Court Care and Rehabilitation Center
180 Burkett Ferry Road Hazlehurst, GA 31539
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0678
F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
sheet, dated [DATE REDACTED], revealed that the nurses assigned to Resident R1 were LPN BB for the day shift (7:00 am-7:00 pm) and LPN HH for the night shift (7:00 pm-7:00 am). Certified Nursing Assistant (CNA) AA was listed as Resident R1's day shift CNA. During an interview on [DATE REDACTED] at 3:09 pm, LPN BB confirmed she worked on [DATE REDACTED].
She stated that she had last checked on Resident R1 when she gave Resident R1 her evening medications, that Resident 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 Resident R1 had passed away, LPN BB stated she found out after the fact (on [DATE REDACTED], 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 REDACTED]), 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 Resident R1's room prior to it becoming known that Resident R1 had passed, LPN BB stated that CNA AA had stepped out in the hall and asked who the nurse was for Resident R1. LPN BB stated that CNA AA was told by LPN CC (the other day shift nurse working with LPN BB on [DATE REDACTED]) that LPN HH (on-coming night shift nurse) had taken over. During an interview on [DATE REDACTED] at 10:58 am, CNA AA confirmed she worked the day shift (7:00 am-7:00 pm) on [DATE REDACTED] and was assigned to Resident R1.
CNA AA stated that around supper time, she went into Resident 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 Resident R1's room and offered to help Resident R1 with her supper, but Resident R1 told her no and said she was not feeling well. CNA AA stated Resident R1 felt cold, so she went and told LPN BB about it and that Resident R1 did not want to eat. CNA AA stated she continued to pass out supper trays. When she came back around to check on Resident R1 again, it was around 6-something, and Resident R1 was cold. CNA AA stated she stepped to the door (of Resident R1's room) and said she needed help, and the nurses came down. CNA AA confirmed that CNA FF also came into Resident R1's room and then told the nurses. During an
interview on [DATE REDACTED] at 1:38 pm, LPN HH stated that on [DATE REDACTED], 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 Resident R1 had passed away. LPN HH stated that she then came back inside and went to Resident R1's room. Resident R1 had no respirations and no pulse, and her eyes were fixed and dilated. LPN HH confirmed
she did not look at Resident R1's code status herself, nor did any of the other nurses who were there. During an
interview on [DATE REDACTED] at 7:43 am, CNA FF (who worked the [DATE REDACTED] night shift 7:00 pm-7:00 am) stated she was alerted to something being wrong by CNA AA, who had come to Resident 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 Resident 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 Resident R1's room. CNA FF went looking for LPN HH and located her outside, and let her know that Resident R1 was deceased and LPN HH came inside.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hazelhurst Court Care and Rehabilitation Center
180 Burkett Ferry Road Hazlehurst, GA 31539
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0835
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.
HAZELHURST COURT CARE AND REHABILITATION CENTER in HAZLEHURST, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HAZLEHURST, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HAZELHURST COURT CARE AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.