Inspection Reports for
Azalea Gardens Nursing Center
530 Hall Street, Wiggins, MS, 39577
Back to Facility Profile4 Reports
Inspection Report — Mar 6, 2025
Routine CMS
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing staffing posting requirements, food safety standards, infection prevention and control practices, and medication administration procedures.
Findings
The facility failed to post daily nursing staffing information in a location accessible to residents and visitors, failed to maintain food safety by improper hand hygiene and storage of overly ripe produce, and failed to ensure proper infection control during medication administration, including failure to discard contaminated equipment and perform hand hygiene.
Deficiencies (3)
F 0732: The facility failed to post daily nursing staffing hours in a location readily accessible to residents and visitors and failed to update the posted staffing for three of four days of the survey.
F 0812: The facility failed to use hand hygiene, discard overly ripe produce, and calibrate a food thermometer prior to checking food temperatures during two kitchen observations.
F 0880: The facility failed to ensure a nurse performed hand hygiene, changed gloves, and discarded a feeding tube syringe after it was dropped onto the floor during medication administration for one resident.
Report Facts
Residents affected: 63
Sweet potatoes observed: 7
Onions observed: 1
Juice cartons placed in refrigerator: 5
Residents reviewed for medication administration: 3
Resident #31 BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed staffing information posting area |
| Director of Nursing | Director of Nursing (DON) | Acknowledged failure to update staffing information and confirmed infection control expectations |
| Administrator | Facility Administrator | Confirmed staffing posting location and infection control expectations |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Acknowledged presence of overly ripe produce and hand hygiene failure |
| Dietary Aide #2 | Dietary Aide | Handled food without hand hygiene after retrieving item from floor |
| Assistant Dietary Manager | Assistant Dietary Manager (ADM) | Confirmed thermometer calibration procedures and food safety expectations |
| LPN #2 | Licensed Practical Nurse | Failed to change gloves, perform hand hygiene, and discard contaminated syringe during medication administration |
| Registered Nurse #2 | Registered Nurse/Infection Preventionist | Confirmed infection control expectations and training |
Inspection Report — Jun 22, 2023
Complaint Investigation CMS
Date: Jun 22, 2023
Visit Reason
The inspection was conducted to investigate the facility's failure to identify and properly manage the use of physical restraints, including full-length bed rails and a lap buddy chair restraint, on 10 of 19 sampled residents.
Complaint Details
The visit was complaint-related, focusing on the use of physical restraints. The findings confirmed the complaint that restraints were used without proper identification, assessment, or care planning.
Findings
The facility failed to identify physical restraints related to full-length bed rails and a lap buddy for 10 residents. Additionally, the facility did not develop care plans for the use of these restraints for the affected residents. The facility confirmed use of restraints without least restrictive measures or entrapment assessments.
Deficiencies (2)
F 0604: The facility failed to ensure residents were free from physical restraints, using full-length bed rails and a lap buddy for 10 residents without proper identification or assessment.
F 0656: The facility failed to develop and implement care plans related to the use of physical restraints for 10 residents, lacking measurable objectives and timeframes.
Report Facts
Residents affected: 10
Sampled residents: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Explained use of lap buddy for Resident #41 and inability of resident to remove it | |
| Licensed Practical Nurse (LPN) #1 | Confirmed use of lap buddy and bed rails for Resident #41 and inability to remove them | |
| Certified Nurse Aide (CNA) #2 | Explained fall prevention measures for Resident #41 including lap buddy and bed rails | |
| Licensed Practical Nurse (LPN) #2/Minimum Data Set (MDS)-Care Plan Nurse | Confirmed failure to develop care plans related to restraints for affected residents | |
| Administrator | Confirmed facility use of full bed rails and lap buddy restraints and discussed removal plans | |
| Director of Nursing (DON) | Confirmed use of restraints and lack of care plans for affected residents |
Inspection Report — Mar 2, 2023
CMS
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding timely notification to residents and their representatives before transfer or discharge.
Findings
The facility failed to provide a written notice of transfer to the Responsible Representative for one of three sampled residents. Interviews and record reviews confirmed the lack of documented notification for Resident #1's transfer to an acute hospital.
Deficiencies (1)
F 0623: The facility failed to provide timely notification to the resident's Responsible Representative before transfer or discharge. Resident #1 was transferred to an acute hospital without documented written notice to the representative.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding notification process but no full name provided | |
| Administrator | Confirmed facility did not provide written notice of transfer |
Inspection Report — Jan 31, 2020
Complaint Investigation CMS
Date: Jan 31, 2020
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to honor residents' rights, specifically related to voting rights, Do Not Resuscitate (DNR) code status, and pain management during wound care.
Complaint Details
The complaint investigation was triggered by concerns that the facility failed to assist residents in voting, failed to honor DNR orders resulting in inappropriate CPR, failed to manage pain during wound care, and failed to maintain accurate and consistent documentation of residents' code status. Immediate jeopardy was identified related to the failure to honor DNR orders and pain management.
Findings
The facility failed to assist residents in exercising their voting rights, failed to honor Resident #74's DNR code status resulting in inappropriate initiation of CPR, failed to follow Resident #74's care plan regarding DNR status, failed to assess and manage pain for Resident #22 during wound care, and failed to monitor and ensure accurate documentation and communication of residents' code status in the medical records. The facility implemented corrective actions including staff in-services, audits, and quality assurance measures.
Deficiencies (5)
F0550: The facility failed to assist three residents to participate in the gubernatorial election on 11/6/2019, violating their right to vote.
F0578: The facility failed to honor Resident #74's DNR code status and initiated CPR when the resident was found unresponsive, resulting in immediate jeopardy to resident health or safety.
F0656: The facility failed to follow Resident #74's care plan for DNR code status and failed to develop and implement Resident #22's care plan for pain medication during wound care.
F0697: The facility failed to assess or administer pain medication for Resident #22 during wound care despite verbal and gestural indications of pain.
F0867: The facility failed to monitor and evaluate the Quality Assessment and Assurance plan to ensure accurate documentation and honoring of residents' advance directives and code status, placing residents at risk of serious harm.
Report Facts
Residents affected: 3
CPR duration: 5
Records reviewed: 77
DNR records: 55
Full code records: 22
Wound size: 1.4
Wound size: 1.2
Potassium level: 8.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Supervisor | Did not verify Resident #74's DNR status before CPR initiation |
| RN #5 | Charge Nurse | Initiated CPR on Resident #74 without verifying DNR status |
| LPN #2 | Assisted with CPR on Resident #74, did not verify DNR status | |
| RN #3 | Wound Care Nurse | Failed to assess and manage pain for Resident #22 during wound care |
| LPN #1 | Accidentally discontinued Resident #64's DNR order in electronic record | |
| Administrator | Oversaw QAA and corrective actions, confirmed failures and corrective measures | |
| Medical Director | Commented on negative outcomes related to failure to honor DNR status | |
| Assistant Director of Nursing | ADON | Responsible for reviewing and monitoring resident code status records |
Viewing
Loading inspection reports...
