Inspection Reports for Azalea Health and Rehabilitation Center

A revisit survey was conducted to verify correction of previous deficiencies.

The revisit survey revealed that the facility was in substantial compliance.

A revisit survey was conducted to verify correction of previously identified deficiencies.

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.

The document is a statement of deficiencies and plan of correction for Azalea Health and Rehabilitation Center following a state inspection.

The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.

A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following prior deficiencies.

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.

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.

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.

The visit included complaint intake related to expired medications found in medication storage rooms and carts.

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.

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.

Complaint Intake Number GA00216701 was investigated in conjunction with the standard survey and was found to be substantiated with no deficiencies cited.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.

An abbreviated/partial extended survey was conducted to investigate complaints #GA00213272 and #GA00214051 from June 8, 2021 through June 10, 2021.

The complaints #GA00213272 and #GA00214051 were found to be unsubstantiated with no deficiencies cited during the investigation.

Complaints #GA00213272 and #GA00214051 were investigated and found to be unsubstantiated with no deficiencies cited.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey to investigate complaints #GA00212126 and #GA00211793.

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.

Complaints #GA00212126 and #GA00211793 were unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00209246.

The complaint was unsubstantiated and no deficiencies were found during the survey.

Complaint #GA00209246 was investigated and found to be unsubstantiated with no deficiencies.

An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00208530.

The complaint GA00208530 was unsubstantiated and no deficiencies were identified during the survey.

Complaint GA00208530 was investigated and found to be unsubstantiated with no deficiencies.

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.

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.

An abbreviated/partial extended survey was conducted to investigate complaints #GA00200589 and #GA00207425.

Both complaints #GA00200589 and #GA00207425 were unsubstantiated, and no deficiencies were identified during the survey.

The survey was complaint-related, investigating complaints #GA00200589 and #GA00207425, both found unsubstantiated with no deficiencies.

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.

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.

An abbreviated/partial extended survey was conducted to investigate complaint GA00195524.

The complaint was unsubstantiated and no deficiencies were found during the survey.

Complaint GA00195524 was investigated and found to be unsubstantiated with no deficiencies.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The survey noted that all previously cited deficiencies had been corrected.

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.

No deficiencies were cited during the complaint and revisit survey conducted from November 7 through November 8, 2018.

Complaint Intake Number GA00192430 was investigated and found to have no deficiencies.

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.

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.

Complaint Intake Number GA00192430 was investigated and found to be in substantial compliance.

A follow-up survey was conducted to verify correction of previously cited deficiencies.

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.

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.

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.

An unannounced Complaint Survey was conducted to investigate complaint # GA 00185313 at Azalea Health and Rehabilitation Center.

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.

Investigation of complaint # GA 00185313; facility found in substantial compliance.

A revisit survey was conducted to verify correction of deficiencies cited in a prior recertification survey on 10/26/17.

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.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The surveyor noted that all previously cited survey tags have been corrected during this follow-up survey.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.

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.

Complaint investigation was conducted on 9/19/17 involving staff and resident interviews, record reviews, and observations throughout the facility.

Based on the information obtained during the investigation, the complaint was unsubstantiated.

Complaint investigation was conducted and found to be unsubstantiated.

A revisit was conducted on 2/9/17 to the standard survey conducted on December 8, 2016, to verify compliance with Medicare/Medicaid regulations.

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.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies had been corrected at the time of the follow-up survey.

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.

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.