Inspection Reports for Azalea Health and Rehabilitation Center
1600 ANTHONY ROAD, AUGUSTA, GA, 30907
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 20, 2021, found the facility in substantial compliance with no deficiencies cited. Earlier inspections identified issues primarily related to maintaining a safe, clean, and comfortable environment in resident rooms and medication management, including expired medications not properly disposed of. Prior reports also noted repeated fire safety deficiencies involving fire walls, sprinkler systems, and fire doors, though no enforcement actions or fines were listed in the available reports. Complaint investigations were mostly unsubstantiated, with one substantiated complaint related to expired medications but no deficiencies cited for that case. The facility appears to have addressed many prior deficiencies over time, showing improvement in recent inspections.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
87 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 2
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to evaluate compliance with nursing staffing requirements and infection prevention and control standards at Azalea Health Center by Harborview.
Findings
The facility failed to ensure a registered nurse was on duty for at least eight consecutive hours on six days, and the Director of Nursing was unclear about RN coverage requirements. Additionally, staff failed to comply with proper hand hygiene and enhanced barrier precautions during resident care, potentially increasing infection risk for residents.
Deficiencies (2)
Failed to ensure the services of a registered nurse for at least eight consecutive hours a day on six days.
Failed to ensure staff complied with proper hand hygiene and enhanced barrier precautions during medication pass and resident care.
Report Facts
Residents present: 87
Days with no RN coverage: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed failing to perform hand hygiene between residents during medication pass |
| LPN DD | Licensed Practical Nurse | Observed failing to perform hand hygiene between residents during medication pass |
| CNA EE | Certified Nurse Aide | Observed not performing hand hygiene and not wearing gown during resident care under Enhanced Barrier Precautions |
| CNA FF | Certified Nurse Aide | Observed not performing hand hygiene and not wearing gown during resident care under Enhanced Barrier Precautions |
| Staffing Scheduler | Interviewed about RN staffing schedule and coverage | |
| Director of Nursing | DON | Interviewed about RN coverage and staffing requirements |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, facility environment, and resident rights.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring proper medication administration without errors or delays, coordinating PASRR Level II assessments for residents with serious mental illness diagnoses, and providing adequate assistance with activities of daily living for several residents.
Deficiencies (7)
Failed to ensure a clean, homelike, and safe environment for one of three units, including cluttered resident rooms, dirty privacy curtains, and needed repairs.
Failed to protect residents from wrongful use of their medications by licensed nursing staff during medication administration.
Failed to coordinate assessments with the pre-admission screening and resident review program; did not submit PASRR Level II for residents with serious mental illness diagnoses.
Failed to provide care and assistance for activities of daily living (ADLs) including bathing, grooming, and hygiene for three residents.
Failed to ensure medication was obtained from the pharmacy in a timely manner for one resident, resulting in delayed administration.
Failed to ensure medication error rate was less than 5 percent; observed 10 medication errors out of 27 opportunities for one resident.
Failed to ensure residents were free from significant medication errors, including delayed and missed medication administration.
Report Facts
Medication errors: 10
Medication error rate: 37.04
Medication administration time: 9
Medication administration delay: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN EE | Registered Nurse | Involved in medication administration observations and interviews regarding medication errors and delays |
| LPN CC | Licensed Practical Nurse | Admitted to providing medication from another resident's supply and confirmed scheduled shower days for resident R8 |
| LPN GG | Licensed Practical Nurse | Notified physician and pharmacy about missing medication and discussed medication availability |
| CNA AA | Certified Nurse Aide | Reported not giving resident R8 a shower in the past month |
| CNA BB | Certified Nurse Aide | Described shower bed use and access issues |
| CNA DD | Certified Nurse Aide | Confirmed resident R8 had not received scheduled shower |
| Director of Nursing | Director of Nursing | Provided multiple interviews confirming expectations for medication administration and ADL care |
| Administrator | Administrator | Confirmed environmental observations and plans to reduce clutter |
| Environmental Services Manager | Environmental Services Manager | Confirmed findings in laundry room |
| Director of Housekeeping | Director of Housekeeping | Confirmed findings in laundry room |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed PASRR Level I status for residents and lack of Level II submissions |
| MDS Director HH | MDS Director | Reviewed EHRs and confirmed PASRR deficiencies |
| Director of Operations | Director of Operations | Reviewed EHRs and discussed PASRR process and staff training |
| Social Services Director | Social Services Director | Newly assigned, responsible for submitting PASRRs, still in training |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, facility environment, and PASRR coordination at Azalea Health Center by Harborview.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring proper medication administration without errors or delays, coordinating PASRR Level II assessments for residents with new mental illness diagnoses, and providing adequate assistance with activities of daily living for some residents. Medication errors and delays were noted, and some residents did not receive scheduled showers or hygiene care.
Deficiencies (7)
Failed to ensure a clean, homelike, and safe environment for one of three units, including cluttered rooms, dirty privacy curtains, and needed repairs.
Failed to protect residents from wrongful use of belongings or money during medication administration by licensed nursing staff.
Failed to coordinate assessments with the pre-admission screening and resident review program; did not submit PASRR Level II for residents with new mental illness diagnoses.
Failed to provide care and assistance for activities of daily living including bathing, grooming, and personal hygiene for some residents.
Failed to ensure medication was obtained from the pharmacy in a timely manner for one resident.
Failed to ensure medication error rate was less than 5 percent; medication errors occurred for one resident with a 37.04 percent error rate.
Failed to ensure residents were free from significant medication errors, including late administration and unavailable medications.
Report Facts
Medication errors: 10
Medication administration opportunities: 27
Medication error rate: 37.04
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN EE | Registered Nurse | Involved in medication administration and interview regarding medication errors and delays for resident R17 |
| LPN CC | Licensed Practical Nurse | Admitted to pulling medication from another resident's supply; involved in medication administration observation |
| Director of Nursing | Director of Nursing | Provided interviews regarding medication administration policies, expectations, and deficiencies |
| Administrator | Administrator | Confirmed environmental observations and plans to reduce clutter |
| Environmental Services Manager | Environmental Services Manager | Confirmed environmental observations |
| Director of Housekeeping | Director of Housekeeping | Confirmed findings in laundry room |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed PASRR Level I status for residents R14 and R294 |
| MDS Director HH | MDS Director | Reviewed EHRs and confirmed PASRR deficiencies |
| Director of Operations | Director of Operations | Reviewed EHRs and discussed PASRR deficiencies and staff training |
| Social Services Director | Social Services Director | New to role; responsible for submitting PASRRs; unaware of some residents' PASRR status |
| CNA AA | Certified Nurse Aide | Reported not giving resident R8 a shower in the past month |
| CNA BB | Certified Nurse Aide | Described shower bed use and access issues |
| CNA DD | Certified Nurse Aide | Confirmed resident R8 did not receive scheduled shower |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify a resident's representative of significant changes, inaccurate Minimum Data Set (MDS) assessments, and failure to provide safe and appropriate respiratory care.
Complaint Details
The complaint investigation found substantiated issues including failure to notify a resident's representative of hospital transfer, inaccurate MDS coding, and inadequate respiratory care equipment maintenance.
Findings
The facility failed to notify the resident representative of a hospital transfer for one resident, miscoded an MDS assessment for another resident, and failed to ensure oxygen equipment was clean and delivering oxygen at the prescribed flow rate for two residents receiving respiratory care.
Deficiencies (3)
Failed to notify the resident representative of the transfer to the acute hospital post fall for Resident #57.
Failed to accurately code one Minimum Data Set Assessment (MDS) for Resident #13, incorrectly indicating an indwelling urinary catheter.
Failed to ensure oxygen equipment was free from dust buildup and failed to deliver oxygen at the flow rate ordered by the physician for Residents #31 and #3.
Report Facts
Residents sampled: 35
Residents receiving respiratory care: 23
Oxygen flow rate order: 2
Oxygen concentrator setting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Confirmed lack of notification to resident representative and responsibility for oxygen concentrator checks |
| Licensed Practical Nurse CC | Unit Manager | Confirmed resident does not have catheter and responsibility for respiratory tubing and filter maintenance |
| Registered Nurse FF | MDS Coordinator for sister facility | Verified miscoding of MDS assessment for Resident #13 |
| Director of Nursing | Director of Nursing (DON) | Confirmed notification failures and responsibility for oxygen equipment maintenance |
| Administrator | Administrator | Stated responsibility of documenting nurse to notify resident representative of changes |
| Housekeeping Supervisor | Housekeeping Supervisor | Stated nurses are responsible for cleaning oxygen concentrator filters |
| Maintenance Director | Maintenance Director (MD) | Stated not responsible for cleaning oxygen filters but willing to start if required |
| VP of Clinical Services | Vice President of Clinical Services | Stated DON is ultimately responsible for ensuring oxygen concentrator filters are cleaned |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify a resident's representative of a hospital transfer, inaccurate Minimum Data Set (MDS) assessment coding, and inadequate respiratory care including improper oxygen equipment maintenance and delivery.
Complaint Details
The complaint investigation revealed failure to notify a resident representative of hospital transfer, inaccurate MDS coding, and inadequate respiratory care including oxygen equipment maintenance and flow rate delivery.
Findings
The facility failed to notify the resident representative of a hospital transfer for one resident, miscoded an MDS assessment for another resident, and failed to ensure oxygen equipment was clean and delivering oxygen at the prescribed flow rate for two residents. Responsibility for notification and equipment maintenance was unclear among staff.
Deficiencies (3)
Failed to notify the resident representative of significant changes including hospital transfer for Resident #57.
Failed to accurately code the Minimum Data Set (MDS) assessment for Resident #13 regarding indwelling catheter status.
Failed to ensure oxygen equipment was free from dust buildup and failed to deliver oxygen at the ordered flow rate for Residents #31 and #3.
Report Facts
Residents sampled: 35
Residents receiving respiratory care: 23
Oxygen flow rate order: 2
Oxygen concentrator setting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Confirmed lack of notification to resident representative and responsibility for oxygen concentrator checks |
| Licensed Practical Nurse CC | Unit Manager | Confirmed Resident #13 catheter status and responsibility for respiratory tubing and filter maintenance |
| Registered Nurse FF | MDS Coordinator for sister facility | Verified MDS miscoding for Resident #13 |
| Director of Nursing | Director of Nursing (DON) | Confirmed notification failures and responsibility for oxygen equipment maintenance |
| Administrator | Facility Administrator | Stated responsibility of documenting nurse for notification and documentation of hospital transfers |
| Housekeeping Supervisor | Housekeeping Supervisor | Stated nurses are responsible for cleaning oxygen concentrator filters |
| Maintenance Director | Maintenance Director (MD) | Stated not responsible for cleaning oxygen filters but willing to start if required |
| VP of Clinical Services | Vice President of Clinical Services | Stated DON is ultimately responsible for ensuring oxygen concentrator filters are cleaned |
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of previous deficiencies.
Findings
The revisit survey revealed that the facility was in substantial compliance.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of previously identified deficiencies.
Findings
The revisit survey revealed the deficiency had been corrected as of 10/26/2021 and the facility was found in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Deficiencies: 0
Date: Oct 25, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Azalea Health and Rehabilitation Center following a state inspection.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 1
Date: Oct 25, 2021
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following prior deficiencies.
Findings
The facility failed to maintain a safe, clean, and comfortable environment in one of 43 rooms due to unrepaired chipped paint and disrepair of the bathroom door jamb in Room 30D. The Maintenance Director had completed repairs on door jambs outside rooms but missed the bathroom door jamb, and the Administrator was unaware of this issue.
Deficiencies (1)
Failed to repair Room 30D bathroom door jamb which had chipped paint and disrepair.
Report Facts
Facility census: 67
Number of rooms: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for conducting and completing environmental audits and repairs | |
| Administrator | Interviewed regarding the condition of the bathroom door jamb and maintenance oversight |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Aug 12, 2021
Visit Reason
A licensure survey was conducted from 8/10/2021 through 8/12/2021, including a complaint intake, to assess the facility's compliance with licensure requirements.
Complaint Details
The visit included complaint intake related to expired medications found in medication storage rooms and carts.
Findings
The facility failed to ensure proper disposal of expired medications in multiple medication storage rooms and medication carts, with numerous expired medications observed and confirmed by staff.
Deficiencies (1)
Failure to ensure proper disposal of expired medication in two of four medication storage rooms and three of three medication carts.
Report Facts
Expired medications observed: 27
Facility census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Confirmed expired medications in medication storage room and medication carts |
| LPN EE | Licensed Practical Nurse | Confirmed expired medications in station two medication cart |
| LPN DD | Licensed Practical Nurse | Confirmed expired medications in station three medication cart |
| Director of Nursing | DON | Confirmed expired medications and provided interview about medication management |
Inspection Report
Routine
Census: 74
Deficiencies: 2
Date: Aug 12, 2021
Visit Reason
A standard survey was conducted from 8/10/2021 through 8/12/2021, including investigation of a complaint intake number GA00216701, which was substantiated with no deficiencies cited.
Complaint Details
Complaint Intake Number GA00216701 was investigated in conjunction with the standard survey and was found to be substantiated with no deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to maintaining a safe, clean, and comfortable environment in resident rooms and medication storage issues including expired medications in multiple medication rooms and carts.
Deficiencies (2)
Facility failed to maintain a safe, clean, and comfortable environment in four of 43 rooms, including unrepaired vanity sink edges, protruding nails, rusted bedside commode frames, unsecured exhaust fan vents, stained curtains and ceiling tiles, and chipped paint.
Facility failed to ensure proper disposal of expired medications in two of four medication storage rooms and three of three medication carts observed, with multiple medications past expiration dates.
Report Facts
Resident census: 74
Expired medications: 4
Expired medications: 4
Expired medications: 11
Expired medications: 5
Expired medications: 3
Rooms with environmental deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Confirmed expired medications in medication storage room and medication cart for station one |
| LPN EE | Licensed Practical Nurse | Confirmed expired medications in medication cart for station two |
| LPN DD | Licensed Practical Nurse | Confirmed expired medications in medication cart for station three |
| DON | Director of Nursing | Confirmed expired medications in medication storage room for station two and discussed medication storage expectations |
| CNA BB | Certified Nursing Assistant | Provided information about residents' abilities to use shared bathroom and maintenance request process |
| Business Office member CC | Ambassador for room 30 | Described daily rounds and environment checks including privacy curtains |
| Maintenance Technician AA | Maintenance Technician | Participated in walk-through identifying environmental concerns |
| Housekeeping Supervisor | Discussed cleaning processes and curtain replacement procedures | |
| Unit Manager | Described maintenance repair request process |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 12, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding the maintenance of a safe, clean, and comfortable environment, as well as proper medication storage and disposal practices.
Findings
The facility failed to maintain a safe and clean environment in several resident rooms, including unrepaired vanity damage, protruding nails, rusted commode frames, stained curtains, and ceiling tiles. Additionally, expired medications were found in multiple medication storage rooms and carts, indicating failure to properly dispose of expired drugs.
Deficiencies (2)
Failed to repair the right front corner of the vanity for a sink, front panel of one drawer on a four-drawer chest, remove protruding nails on walls, ensure bedside commode frame was free from rust and corrosion, secure exhaust fan vent, and maintain clean privacy curtains and ceiling tiles.
Failed to ensure proper disposal of expired medications in two of four medication storage rooms and three of three medication carts observed.
Report Facts
Rooms with environmental deficiencies: 4
Expired medications in station one medication room: 4
Expired medications in station one medication cart: 4
Expired medications in station two medication room: 11
Expired medications in station two medication cart: 5
Expired medications in station three medication cart: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant BB | Certified Nursing Assistant | Interviewed regarding residents' ability to use shared bathroom and maintenance reporting process. |
| Maintenance Technician AA | Maintenance Technician | Participated in walk-through identifying environmental concerns. |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning processes and curtain replacement. |
| Business Office member CC | Ambassador | Interviewed about daily rounds and observation of residents' environment. |
| Licensed Practical Nurse FF | Licensed Practical Nurse | Confirmed expired medications in station one medication room and cart. |
| Director of Nursing | Director of Nursing | Confirmed expired medications in station two medication room and discussed medication storage policies. |
| Licensed Practical Nurse EE | Licensed Practical Nurse | Confirmed expired medications in station two medication cart. |
| Licensed Practical Nurse DD | Licensed Practical Nurse | Confirmed expired medications in station three medication cart. |
Inspection Report
Life Safety
Census: 74
Capacity: 99
Deficiencies: 0
Date: Aug 11, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Report Facts
Census: 74
Total Capacity: 99
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 10, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00213272 and #GA00214051 from June 8, 2021 through June 10, 2021.
Complaint Details
Complaints #GA00213272 and #GA00214051 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints #GA00213272 and #GA00214051 were found to be unsubstantiated with no deficiencies cited during the investigation.
Report Facts
Complaint numbers investigated: 2
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey to investigate complaints #GA00212126 and #GA00211793.
Complaint Details
Complaints #GA00212126 and #GA00211793 were unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended practices for COVID-19. Complaints were unsubstantiated and no regulatory violations were cited.
Report Facts
Total census: 65
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 4, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209246.
Complaint Details
Complaint #GA00209246 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00208530.
Complaint Details
Complaint GA00208530 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint GA00208530 was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Oct 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00200589 and #GA00207425.
Complaint Details
The survey was complaint-related, investigating complaints #GA00200589 and #GA00207425, both found unsubstantiated with no deficiencies.
Findings
Both complaints #GA00200589 and #GA00207425 were unsubstantiated, and no deficiencies were identified during the survey.
Inspection Report
Routine
Census: 75
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 regarding emergency preparedness and infection control regulations for COVID-19.
Report Facts
Total census: 75
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 17, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195524.
Complaint Details
Complaint GA00195524 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 11, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
The inspection was conducted as a Complaint Survey in conjunction with a revisit survey to investigate Complaint Intake Number GA00192430 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint Intake Number GA00192430 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint and revisit survey conducted from November 7 through November 8, 2018.
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
A revisit survey was conducted in conjunction with a complaint investigation (Complaint Intake Number GA00192430) to verify correction of deficiencies cited in the prior Recertification survey conducted in September 2018.
Complaint Details
Complaint Intake Number GA00192430 was investigated and found to be in substantial compliance.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected. The complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Report Facts
Resident Census: 84
Inspection Report
Follow-Up
Capacity: 82
Deficiencies: 1
Date: Nov 7, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility failed to maintain fire walls as required, with open penetrations above the ceiling at nurse station #1 and mixed fire caulking or sheet rock mud used to seal penetrations throughout. This is a repeat violation noted on follow-up inspection.
Deficiencies (1)
Failed to maintain fire walls with open penetration above ceiling at nurse station #1 and improper sealing of penetrations.
Report Facts
Total residents at risk: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during repeat tour of the facility |
Inspection Report
Life Safety
Census: 82
Capacity: 99
Deficiencies: 6
Date: Sep 17, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain fire alarm batteries, fire sprinkler system components, fire doors, fire walls, electrical systems, and the presence of prohibited portable space heaters. These deficiencies could place 82 residents and staff at risk in the event of a fire.
Deficiencies (6)
Failed to maintain fire alarm batteries; batteries were not dated with manufacturer's dates.
Failed to maintain fire sprinkler system and components; electrical wiring on sprinkler piping above ceiling at room 28 and fire sprinkler system yellow tagged with deficiencies.
Failed to maintain fire doors; fire door #10 does not close securely and overlaps.
Failed to maintain fire walls; open penetration above ceiling at nurse station #1 and mixed fire caulking used to seal penetrations.
Failed to maintain electrical system; open junction boxes found at nurse station 1 above fire wall and above fire wall at room 28.
Failed to maintain portable electric space heaters; a portable electric space heater was found plugged in next to an office chair in the Director of Education Office.
Report Facts
Residents at risk: 82
Certified beds: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Feb 27, 2018
Visit Reason
An unannounced Complaint Survey was conducted to investigate complaint # GA 00185313 at Azalea Health and Rehabilitation Center.
Complaint Details
Investigation of complaint # GA 00185313; facility found in substantial compliance.
Findings
The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483 for Long Term Care Facilities.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Dec 28, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in a prior recertification survey on 10/26/17.
Findings
All deficiencies cited during the recertification survey on 10/26/17 were found to be corrected during the revisit survey on 12/27-12/28/17.
Report Facts
Facility census: 86
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 14, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this follow-up survey.
Inspection Report
Life Safety
Census: 87
Capacity: 99
Deficiencies: 4
Date: Oct 25, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain smoke doors, fire alarm system inspections, sprinkler system maintenance, and exposed wiring hazards, placing residents and staff at risk in the event of fire.
Deficiencies (4)
Smoke door #5 did not close securely against smoke or fire travel.
Facility failed to maintain proper inspections on fire alarm system; conflicting inspection reports and unlicensed company involvement.
Sprinkler system maintenance and testing deficiencies; painted fire sprinkler heads found in two storage/supply rooms.
Exposed wiring due to missing light globe in central supply room.
Report Facts
Residents at risk: 87
Certified beds: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 19, 2017
Visit Reason
Complaint investigation was conducted on 9/19/17 involving staff and resident interviews, record reviews, and observations throughout the facility.
Complaint Details
Complaint investigation was conducted and found to be unsubstantiated.
Findings
Based on the information obtained during the investigation, the complaint was unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 9, 2017
Visit Reason
A revisit was conducted on 2/9/17 to the standard survey conducted on December 8, 2016, to verify compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities, effective on 1/13/17 as alleged in their Plan of Correction.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 30, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected at the time of the follow-up survey.
Inspection Report
Life Safety
Census: 78
Deficiencies: 8
Date: Dec 12, 2016
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements including hazardous area enclosures, sprinkler system maintenance, portable fire extinguishers, corridor doors, smoke barriers, smoking regulations, portable space heaters, and electrical equipment power cords and extension cords. Multiple deficiencies were observed that could place all 78 residents at risk in the event of a fire.
Deficiencies (8)
Gasoline powered equipment and gasoline can stored inside the facility, violating hazardous area enclosure requirements.
Failure to maintain sprinkler system properly, including loaded sprinkler heads and obstructions.
Damaged 'K' type fire extinguisher in kitchen.
Corridor doors did not create a smoke-resistant barrier; some doors did not close and latch properly.
Smoke barriers had open penetrations unchecked in multiple locations.
Smoking policy not maintained properly; cigarette butts found in courtyard; smoking signs not posted.
Portable space heaters found in unauthorized areas including Administrator's and Business offices.
Power strips in patient care vicinity used improperly; power strips on floors and under desks not mounted off flooring.
Report Facts
Residents at risk: 78
Power strips observed: 6
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