Inspection Reports for Azalea Health and Rehabilitation
300 CEDAR ROAD, METTER, GA, 30439
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2024, found that all previously cited deficiencies had been corrected. Earlier inspections showed a mix of compliance and issues, including life safety code violations related to sprinkler maintenance and emergency preparedness, as well as some deficiencies in resident care documentation and medication management. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in early 2023 regarding failure to timely notify a physician of a resident’s change in condition. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent surveys indicating correction of prior deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
64 residents
Based on a June 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 1, 2024
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 have been corrected.
Inspection Report
Census: 64
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
A Federal Focused Concern Survey was completed by the Centers for Medicare & Medicaid Services (CMS) on June 10, 2024.
Findings
The facility was found in compliance with Medicare regulations at 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Renewal
Deficiencies: 0
Date: May 19, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
No State Health deficiencies were cited during the survey conducted from May 17, 2024 through May 19, 2024.
Inspection Report
Routine
Census: 65
Deficiencies: 1
Date: May 19, 2024
Visit Reason
A standard survey was conducted at Azalea Health and Rehabilitation from May 17, 2024, through May 19, 2024. In addition, Complaint Intake Number GA00242024 was investigated in conjunction with this standard survey and was unsubstantiated.
Complaint Details
Complaint Intake Number GA00242024 was investigated in conjunction with the standard survey and was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations related to 42 C.F.R. Part 483, Subpart B. A deficiency was identified for failure to complete and transmit a discharge assessment in a timely manner for one resident (R51).
Deficiencies (1)
Failure to ensure a discharge assessment was completed and transmitted in a timely manner for one resident (R51).
Report Facts
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed on 5/19/2024 regarding the missing discharge assessment for resident R51. |
Inspection Report
Life Safety
Census: 66
Capacity: 89
Deficiencies: 8
Date: May 18, 2024
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, with multiple deficiencies observed affecting various smoke compartments and residents. Issues included obstructed corridor width, sprinkler system maintenance failures, painted sprinkler heads, missing light fixture globes, improper wiring, uncovered junction boxes, and unsecured oxygen tanks.
Deficiencies (8)
Failed to maintain corridor width; A Hall corridor exit was impeded by a trash can.
Failed to ensure storage is below 18 inches of sprinkler head in A Hall storage room.
Failed to ensure sprinkler heads were free of paint in Activities Director and Social Services offices.
Sprinkler riser in laundry room was yellow tagged.
Failed to install a globe on the light fixture in A Hall storage room.
Extension cord used as permanent wiring for AC unit in A Hall attic.
Junction box in A Hall attic entrance was missing a cover.
Oxygen tank in A Hall day room was not secure.
Report Facts
Smoke compartments affected: 6
Residents potentially affected: 66
Census: 66
Total capacity: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during the facility tour on 5/18/2024. | |
| Activities Director | Named in relation to painted sprinkler heads deficiency. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00238770.
Complaint Details
Complaint #GA00238770 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Azalea Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 2, 2023 Recertification and Complaint surveys.
Findings
All deficiencies cited during the February 2, 2023 Recertification and Complaint surveys were found to be corrected.
Inspection Report
Routine
Deficiencies: 2
Date: Feb 2, 2023
Visit Reason
A State Licensure survey was conducted at Azalea Health and Rehabilitation from January 30, 2023 through February 2, 2023 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies including failure to timely notify a resident's physician of a change in condition, resulting in delayed treatment, and a medication error rate exceeding 5% due to missed or incorrect medication administration.
Deficiencies (2)
Failure to notify the resident's physician in a timely manner when there was a change in condition for 1 of 3 sampled residents, resulting in delayed ordering and completion of a scan.
Medication administration errors observed with a 5.71% error rate, including failure to administer ordered doses of docusate sodium and delayed release aspirin.
Report Facts
Medication administration opportunities observed: 35
Medication errors: 2
Medication error rate (%): 5.71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Prepared medication for resident #33 and admitted to medication error |
| LPN 5 | Licensed Practical Nurse | Prepared medication for resident #6 and admitted to medication error |
| LPN 10 | Licensed Practical Nurse | Noted resident complaints and completed communication form related to resident #46's leg pain |
| Director of Nursing | Director of Nursing | Provided statements regarding notification procedures and medication administration expectations |
| APRN | Advanced Practice Registered Nurse | Provided clinical assessment and treatment plan for resident #46 |
| Medical Director | Medical Director | Provided statements regarding communication form review and resident pain assessment |
| Administrator | Administrator | Provided statements regarding staff expectations for assessment and communication |
Inspection Report
Standard Survey Complaint Investigation
Census: 44
Deficiencies: 3
Date: Feb 2, 2023
Visit Reason
A standard survey was conducted from January 30, 2023 through February 2, 2023, including investigation of two complaint intake numbers GA00227473 and GA00230011, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake number GA00227473 was unsubstantiated. Complaint Intake number GA00230011 was substantiated with deficiencies related to failure to timely notify the physician of a resident's change in condition.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. One complaint intake was substantiated with deficiencies related to failure to timely notify a physician of a resident's change in condition. Additionally, medication administration errors and improper medication storage were identified.
Deficiencies (3)
Failure to notify the resident's physician in a timely manner when there was a change in condition for 1 of 3 sampled residents (Resident #46).
Medication error rate exceeded 5%, with two errors out of 35 opportunities observed for 2 of 3 residents (#33 and #6).
Failure to store medications properly for 3 of 22 residents (#14, #21, #30) on Hall B's medication cart; medications were pre-poured and not labeled properly.
Report Facts
Resident census: 44
Medication error rate: 5.71
Medication errors: 2
Medication administration opportunities observed: 35
Residents with medication storage issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 10 | Licensed Practical Nurse | Named in failure to timely notify physician finding related to Resident #46 |
| LPN 5 | Licensed Practical Nurse | Named in failure to timely notify physician finding related to Resident #46 |
| LPN 1 | Licensed Practical Nurse | Named in failure to timely notify physician finding related to Resident #46 |
| APRN | Advanced Practice Registered Nurse | Named in failure to timely notify physician finding related to Resident #46 |
| Director of Nursing | Director of Nursing | Named in failure to timely notify physician finding and medication administration findings |
| Medical Director | Medical Director | Named in failure to timely notify physician finding related to Resident #46 |
| LPN 4 | Licensed Practical Nurse | Named in medication administration error finding |
| LPN 5 | Licensed Practical Nurse | Named in medication administration error finding |
| LPN 17 | Licensed Practical Nurse | Named in medication storage deficiency |
| Consultant Pharmacist | Consultant Pharmacist | Named in medication storage deficiency |
| Administrator | Administrator | Named in medication administration and storage findings |
Inspection Report
Life Safety
Census: 44
Capacity: 89
Deficiencies: 2
Date: Jan 31, 2023
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program and to perform a Life Safety Code Survey related to sprinkler system maintenance and compliance with fire safety regulations.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements due to lack of documentation showing annual updates to the emergency plan. Additionally, the sprinkler system was not properly maintained, with issues including rusted/corroded sprinklers, painted sprinkler heads, and a damaged sprinkler deflector, affecting the entire building.
Deficiencies (2)
Emergency Preparedness Program plan was not updated and accepted annually as required.
Sprinkler system was not properly maintained, including rusted/corroded sprinklers in kitchen, painted sprinkler heads in Bath 2A, and damaged sprinkler deflector in dining room.
Report Facts
Census: 44
Total licensed beds: 89
Inspection duration: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 1, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00218417 and #GA00220236.
Complaint Details
Complaint #GA00218417 was substantiated with no deficiencies cited. Complaint #GA00220236 was unsubstantiated.
Findings
Complaint #GA00218417 was substantiated with no deficiencies cited. Complaint #GA00220236 was unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 15, 2021
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 during the follow-up visit.
Inspection Report
Deficiencies: 0
Date: Nov 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Azalea Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 0
Date: Nov 8, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2021-09-23.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
Licensure survey conducted from 2021-09-21 through 2021-09-23 to assess compliance for facility licensure.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Sep 23, 2021
Visit Reason
A standard survey was conducted from 9/21/21 through 9/23/21, including investigation of Complaint Intake Number GA00215868 related to visitation rights and COVID-19 protocols.
Complaint Details
Complaint Intake Number GA00215868 was investigated in conjunction with the standard survey. The complaint concerned denial of visitation rights to a fully vaccinated resident after hospital readmission. The complaint was substantiated by findings.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, specifically failing to allow visitation for one fully vaccinated resident after readmission despite policies permitting visitation under certain conditions. The facility maintained quarantine for 14 days post-hospital readmission regardless of vaccination status and COVID test results, and visitation was limited to window visits during a recent COVID outbreak.
Deficiencies (1)
Failed to ensure one fully vaccinated resident was allowed visitation after readmission to the facility.
Report Facts
Resident census: 53
Sample size: 27
COVID quarantine duration: 14
COVID outbreak duration: 32
Staff vaccination rate: 96
Resident vaccination rate: 96
Unvaccinated staff count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Provided information about quarantine policies, vaccination rates, visitation restrictions, and COVID outbreak |
| Administrator | Administrator | Provided information about current visitation policies and COVID status |
Inspection Report
Life Safety
Census: 53
Capacity: 89
Deficiencies: 1
Date: Sep 21, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failure to properly seal penetrations in a 1-hour rated wall affecting two smoke compartments in the B wing, specifically an unsealed penetration in the attic area above the Day Room and Nurses station.
Deficiencies (1)
Failed to properly seal penetrations in 1 hour rated wall affecting 2 smoke compartments (B wing).
Report Facts
Census: 53
Certified Beds: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of unsealed penetration in 1 hour rated wall during facility tour |
Inspection Report
Routine
Census: 53
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Total census: 53
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Date: Jun 16, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and had implemented recommended practices to prepare for COVID-19.
Report Facts
Total census: 69
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
A standard survey was conducted at Azalea Health and Rehabilitation from October 1, 2018 through October 4, 2018 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 75
Capacity: 89
Deficiencies: 0
Date: Oct 2, 2018
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 substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 3, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from May 2, 2018 through May 3, 2018 to investigate complaint #GA00188341.
Complaint Details
Complaint #GA00188341 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 20, 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 during the follow-up survey.
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Date: Nov 2, 2017
Visit Reason
A standard survey was conducted at Azalea Health and Rehabilitation from October 30, 2017 through November 2, 2017 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 75
Capacity: 96
Deficiencies: 2
Date: Oct 30, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system installation.
Findings
The facility was found not in substantial compliance due to failure to provide compliant sprinkler system coverage per NFPA 101 and NFPA 13 standards. Specific deficiencies included a pendent dry sprinkler head obstructed by a light fixture in the 'B' wing patio and inadequate sprinkler coverage in the laundry area.
Deficiencies (2)
Pendent dry sprinkler head obstructed by a surface mounted light fixture in 'B' wing patio.
Inadequate sprinkler coverage in laundry area; sprinkler head located greater than allowed distance from far wall over dryer.
Report Facts
Census: 75
Total Capacity: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Landolt | Named in initial comments section | |
| Staff M | Confirmed sprinkler system deficiencies during tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 1, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
All previously cited violations were corrected as noted during the follow-up survey.
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Date: Mar 9, 2017
Visit Reason
A Standard Survey was conducted at Azalea Health and Rehabilitation from March 6, 2017 to March 9, 2017, including an investigation of Complaint Intake Number GA00161940.
Complaint Details
Complaint GA00161940 was investigated and found not substantiated.
Findings
The facility was found to be in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. The complaint was not substantiated and no deficiencies were cited.
Report Facts
Resident Census: 75
Inspection Report
Life Safety
Census: 75
Capacity: 89
Deficiencies: 2
Date: Mar 7, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance due to failure to maintain emergency lighting outside egress exits and failure to maintain safe wiring practices, including open and exposed wiring in the ceiling on the 'B' porch, placing residents at risk during emergencies.
Deficiencies (2)
Emergency lighting not provided outside of any egress exits to illuminate the egress pathway during power failure.
Open and exposed wiring discovered in the ceiling on the 'B' porch, failing to maintain safe wiring practices.
Report Facts
Census: 75
Total Capacity: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of emergency lighting and wiring deficiencies during tour |
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