Inspection Reports for
Azalea Gardens Nursing Center

The facility was found not in compliance with state licensure requirements due to failure to protect residents' rights to privacy and confidentiality and failure to maintain safe food handling procedures. Specifically, visual privacy was not provided for some residents and personal care information was improperly posted, and food storage practices were unsanitary with spoiled produce and improper ice scoop storage.

The facility was found not in compliance with multiple requirements including food safety, resident privacy, safe environment, comprehensive care planning, nutrition maintenance, tube feeding management, and quality assurance. Deficiencies included unsanitary food storage, lack of visual privacy for residents, inaccessible overhead light cords, incomplete care plans for hospice and weight loss, inadequate monitoring of PEG tube sutures, and failure to sustain improvements in food storage practices.

The facility was found to be in compliance with all applicable Life Safety Code requirements. No deficiencies were cited during this survey.

Two complaint investigations were conducted: CI MS #2719790 related to administration and CI MS #2720458 related to a resident fall with injuries. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Two complaint investigations were conducted: CI MS #2719790 regarding administration and CI MS #2720458 regarding a resident fall with injuries. The facility was found in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.

CI MS #2593840 was investigated for an allegation of neglect related to a resident's leg pain and subsequent fractured femur resulting in amputation. The complaint was not substantiated as no deficiencies were cited.

During the survey, the State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.

CI MS #2593840 was investigated for an allegation of neglect related to a resident's leg pain and subsequent fractured femur resulting in amputation. The complaint was not substantiated as no deficiencies were cited.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint investigations MS #28836 and MS #28737 were conducted; MS #28836 involved a fall with major injury and MS #28737 involved verbal abuse. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint Investigations MS #28836 and MS #28737 were conducted; MS #28836 involved a fall with major injury and MS #28737 involved verbal abuse. The facility was found in compliance with no deficiencies cited.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

No deficiencies were cited.

The facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code. The State Agency is recommending that the facility be placed back in compliance effective 05/02/25.

This document is a desk review confirming the facility's corrective measures after the Life Safety Code recertification survey. The facility remains out of compliance due to deficiencies cited in the Life Safety Code survey.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm as of 04/10/25. However, deficiencies remain from a prior Life Safety Code recertification survey conducted on 03/05/25.

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.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to deficiencies in nurse staffing posting, food safety practices, and infection prevention and control.

The facility was found not in compliance with state licensure requirements, citing deficiencies in safe food handling procedures and infection control practices.

The facility failed to properly install the fire alarm system and failed to maintain the required 30-minute fire resistance rating for smoke barrier walls, affecting all residents in the facility.

The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

The facility failed to have a properly installed fire alarm control panel and system as per NFPA 101 section 9.6.6, including pull stations that were too high and missing horn/strobe devices.

CI MS #24473 was investigated related to neglect. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint number CI MS #24473 was investigated related to neglect. The facility was found in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint number CI MS#23290 was investigated related to resident left wet for extended periods and not receiving care per physician orders. The complaint was not substantiated as no deficiencies were cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

CI MS#23290 was investigated related to a resident left wet for extended periods and not receiving care per physician orders. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 07/28/23.

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 07/28/23.

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.

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.

M190 - The facility failed to identify physical restraints related to the use of full-length bed rails and a lap buddy for ten of 19 sampled residents. The facility did not try least restrictive measures before implementing full bed rails and did not assess residents for entrapment.

The facility was found not in compliance due to failure to identify physical restraints related to the use of full-length bed rails and a lap buddy for 10 of 19 sampled residents, and failure to develop comprehensive care plans for these restraints.

The facility was found to be in compliance with the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

Complaint CI MS#26995 was investigated; the facility was found in compliance with no deficiencies cited.

The facility was found to be in compliance with no deficiencies cited during this desk review.

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.

The SA investigated CI MS #20451 for grooming, verbal abuse, and medications and cited no deficiencies. The SA investigated CI MS #20490 for Responsible Representative not being notified and cited no deficiencies.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited for either complaint investigation.

Complaint investigation CI MS #20490 alleged failure to notify the Responsible Representative. The deficiency was substantiated with citation of F623.

The facility was found not in compliance due to failure to provide a written notice of transfer to the Responsible Representative for one resident. The facility admitted the mistake and has implemented corrective actions to ensure timely notification for future transfers.

Complaint Investigation MS #18810, MS #19037, and MS #19424 were not substantiated; MS #19424 was not substantiated for safety due to a resident fall; MS #19037 was not substantiated for misappropriation, dignity/respect, nursing services, and medication issues; MS #18810 was not substantiated for verbal abuse, medication administration, staffing, dietary services, and call lights.

The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.

Complaint Investigation numbers MS #18810, MS #19037, and MS #19424 were investigated and not substantiated; no deficiencies were cited.

The facility was found to be in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19. During the complaint investigation, the SA determined the facility was in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

CI MS #16992 involved a choking incident which resulted in the death of Resident #1. The complaint was substantiated with deficiencies cited.

The facility failed to ensure Resident #1, a known choking risk with impulsive behaviors, was supervised during meals, resulting in choking, aspiration, and death. The facility also failed to report the incident timely, revise the care plan with therapy recommendations, provide adequate staffing and supervision during meals, and implement effective quality assurance monitoring.

The facility was found to be in compliance with infection control regulations and has implemented the recommended practices by CMS and CDC to prepare for COVID-19.

The facility failed to prevent the spread of infection by co-horting residents with COVID-19 positive status together with residents who only had signs and symptoms of COVID-19, placing them in shared rooms separated only by curtains. This practice increased the risk of transmission among residents.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

CI MS #16867: Complaint investigation regarding Neglect, Quality of Care related to Responsible Party Not Notified, Quality of Care related to Inappropriate Feeding Assistance for WT Loss, and Physical Environment related to Safe Environment Not Provided. The complaint was unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

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.

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.

The facility was found not in compliance with Medicare and Medicaid requirements due to failure to honor Resident #74's DNR code status, resulting in inappropriate initiation of CPR. The facility also failed to accurately document code status for Residents #31 and #64, and failed to assess and manage pain for Resident #22 during wound care. The Quality Assurance program failed to monitor and ensure compliance with code status documentation and resident rights.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident rights, advance directives, care planning, quality of care, and pressure ulcer treatment. Fire safety deficiencies were also noted.

CI MS #15813 & CI MS #16089: Complaint investigation conducted and found unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.