Douglasville Center for Nursing and Healing LLC

In the surveyor’s words

From the most serious findings on record at Douglasville Center for Nursing and Healing LLC, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 30, 2025

  Based on observations, record reviews, staff and resident interviews, and review of the facility policy Discharge and Transfer Policy, the facility failed to ensure that treatment was provided in a timely manner following a right hip fracture for one of three residents (R1). Actual harm was identified on 8/24/2025 when R1 fell and suffered a right hip fracture that was not recognized until 8/25/2025 when the resident was sent to the hospital and had to undergo surgery for an intertrochanteric fracture of the right hip.Findings include:A review of the facility policy titled Discharge and Transfer Policy, revised 7/18/2025, did not reveal details regarding emergency transfers.Review of the electronic medical record (EMR) for R1 revealed diagnoses including, but not limited to, cerebral… […]

• Actual harm, isolatedF656Oct 3, 2023

  Based on record review, review of the facility policy titled Comprehensive Person-Centered Care Plans, and resident and staff interviews, the facility failed to implement the care plan for two of 56 sampled residents (R) (R19 and R36). Actual harm occurred on 3/14/2023 when R19 sustained an acute fracture of the proximal fibular diaphysis after falling from the bed when one Certified Nursing Assistant (CNA) failed to follow the plan of care for Activities of Daily Living (ADL) care interventions. Findings included: A review of the facility policy titled, Comprehensive Person-Centered Care Plans, dated Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. […]

• Actual harm, isolatedF689Oct 3, 2023

  Based on record review, observations, and interviews, the facility failed to ensure that three of 54 sampled residents (R19, R40, and R36) were free of accidents related to not following the plan of care for fall risk for R19 and R36 and not completing neuro checks for R40. Also, the facility failed to store chemicals in a safe and secure manner to prevent accidents. Actual harm occurred on 3/14/2023 when R19 sustained an acute fracture of the proximal fibular diaphysis after falling from the bed when one Certified Nursing Assistant (CNA) failed to follow the plan of care for ADL care interventions. […]

• Actual harm, isolatedF690Oct 3, 2023

  Based on record review, interviews, and review of the facility's policy titled Bowel Elimination Protocol the facility failed to implement interventions to prevent discomfort for one of 54 sampled residents (R) (R8). Actual harm was identified to have occurred on 6/28/2023 when R8 was sent out to an acute care hospital for fecal impaction. Findings included: A review of an undated facility's policy titled, Bowel Elimination Protocol revealed that it is the responsibility of nursing personnel to document, monitor, and implement appropriate measures relative to the management of bowel function. […]

• No harm, potential for more than minimal, widespreadF812Jun 19, 2026

  Based on observations, staff interviews, and the facility policy titled, Food Receiving and Storage, the facility failed to ensure food was not expired. This had the potential to affect 183 of 213 residents receiving food out of the kitchen. This failure had the potential to spread food borne illness. Findings include: During an observation and interview on 06/15/2026 at 8:44 AM, with the Dietary Manager (DM) present, expired and deteriorated foods were observed in the walk-in refrigerator. The items included seven containers of fresh strawberries with mold throughout each container, three melons with mold on the exterior, and one metal container of rice with a discard date of 06/09/2026. […]