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Complaint Investigation

Macon Rehabilitation And Healthcare

September 2, 2025 · Macon, GA · 505 Coliseum Drive
Citations 2
CMS Rating 2/5
Beds 100
Provider ID 115362
Healthcare Facility
Macon Rehabilitation And Healthcare
Macon, GA  ·  View full profile →
Inspection Summary

MACON REHABILITATION AND HEALTHCARE in MACON, GA — inspection on September 2, 2025.

Found 2 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.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA), specifically an alleged head injury, within the required time frame for one of three sampled residents (R) (R1).Findings include:Review of the facility's policy titled Abuse Prevention Policy, with a reviewed date of [DATE], revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in seriously bodily injury, to the Administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term facilities in accordance with State Law).

Review of the Facility Incident Report Form revealed the SSA was notified on [DATE] and indicated an off-campus injury at dialysis.

The alleged incident was reported to have taken place on [DATE] at 3:00 pm.

The details of the incident noted that the facility received notification that R1 was sent to the emergency room and arrived at the emergency room at 7:45 am.

Per dialysis, he was sent due to a hematoma to the head that was bleeding profusely. R1 received care in the emergency room until he was pronounced deceased sometime after noon.

Per the Coroner, a computed tomography scan (CT) was completed during his course of care at the emergency room that showed a subarachnoid hemorrhage.

The Administrator reported to the Coroner that R1 was picked up from the facility, and transport started at 5:20 am, and per the transport team, arrived at the dialysis center at 5:25 am.

Per transport crew interview and written statements, the resident was picked up from the facility with no apparent signs of injury or bleeding to his head or face.

They deny any incident during transport and stated the resident arrived to dialysis with no injury and was placed in care of his assigned dialysis nurse.

The resident was in the care of the dialysis center for over two hours prior to his transfer to the hospital.

Review of the facility's final investigative summary, dated [DATE], revealed that it was sent to the SSA and noted that, in conclusion, the facility did not substantiate that R1 was injured or involved in any incident at the facility that would have caused the head injury.

The facility had remained in contact with the local County Investigator in order to assist with any additional information they may need.

During an interview with the Administrator on [DATE] at 2:30 pm, she stated she was notified on the evening of [DATE] by the Coroner that the resident was deceased .

She stated she talked to the Coroner again later that evening, and he reported to her that the resident had a hematoma and a subarachnoid hemorrhage.

She confirmed that she submitted the initial report on [DATE] because she wasn't sure what happened.

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

09/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Macon Rehabilitation and Healthcare

505 Coliseum Drive Macon, GA 31217

SUMMARY STATEMENT OF DEFICIENCIES

thinners were administered.

Dialysis staff AA stated the wound appeared to be a straight line, like a scrape on the back of R1's head that had reopened. He immediately applied pressure, and an ambulance was called to transport R1 to the emergency room.

The clinic manager stated she would speak to her legal team about providing statements from the nurses and patients that were there during the incident.

Review of the [DATE] Coroner's Death Investigation Report noted the resident came into the emergency room from dialysis on [DATE] at 7:45 am. CT showed subarachnoid hemorrhage.

The Coroner noted the cause of death on discharge as renal failure.

The date and time of death were [DATE] at 12:25 pm.The Georgia Death Certificate noted the resident was pronounced deceased on [DATE] at 12:25 pm.

The immediate cause of death was cardiac arrest due to respiratory failure and renal failure.

During an interview with the Administrator on [DATE] at 2:30 pm, she stated she was notified of the resident's death on the evening of [DATE] by the Coroner, who also told her that the resident had a hematoma and a subarachnoid hemorrhage.

She stated that when she attempted to call the dialysis clinic, the phone would just ring and ring, forcing her to leave a voicemail message.

However, she never received a returned call from the dialysis clinic and she did not go to the clinic to discuss the incident with management at the dialysis clinic.

She further stated that when she spoke to the investigator, the investigator told her she would talk to the dialysis clinic staff, so she just turned the investigation over to her.

She stated the investigator never got back with her.

She stated she called the Sheriff's Office on [DATE] to obtain a copy of the investigator's report, and was told she would have to come to the office to obtain a copy.

Facility ID:

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 MACON, 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 MACON REHABILITATION AND HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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