Inspection Reports for Azalea Health and Rehabilitation

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 have been corrected.

A Federal Focused Concern Survey was completed by the Centers for Medicare & Medicaid Services (CMS) on June 10, 2024.

The facility was found in compliance with Medicare regulations at 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.

The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.

No State Health deficiencies were cited during the survey conducted from May 17, 2024 through May 19, 2024.

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.

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).

Complaint Intake Number GA00242024 was investigated in conjunction with the standard survey and was unsubstantiated.

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.

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.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00238770.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint #GA00238770 was investigated and found to be unsubstantiated with no deficiencies cited.

A Follow-Up Survey was conducted to verify correction of previously cited survey tags.

All previously cited survey tags have been corrected as noted by the surveyor.

The document is a statement of deficiencies and plan of correction for Azalea Health and Rehabilitation, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A revisit survey was conducted to verify correction of deficiencies cited during the February 2, 2023 Recertification and Complaint surveys.

All deficiencies cited during the February 2, 2023 Recertification and Complaint surveys were found to be corrected.

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.

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.

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.

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.

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.

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.

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.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00218417 and #GA00220236.

Complaint #GA00218417 was substantiated with no deficiencies cited. Complaint #GA00220236 was unsubstantiated and no deficiencies were cited.

Complaint #GA00218417 was substantiated with no deficiencies cited. Complaint #GA00220236 was unsubstantiated.

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 during the follow-up visit.

The document is a statement of deficiencies and plan of correction for Azalea Health and Rehabilitation, indicating a regulatory inspection was conducted.

The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.

A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2021-09-23.

All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.

Licensure survey conducted from 2021-09-21 through 2021-09-23 to assess compliance for facility licensure.

No deficiencies were identified during the licensure survey.

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.

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.

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.

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.

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.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.

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.

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.

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.

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.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.

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 substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.

An Abbreviated/Partial Extended Survey was conducted from May 2, 2018 through May 3, 2018 to investigate complaint #GA00188341.

The complaint investigation was unsubstantiated.

Complaint #GA00188341 was investigated and found to be unsubstantiated.

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 during the follow-up survey.

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.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.

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.

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.

A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.

All previously cited violations were corrected as noted during the follow-up survey.

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.

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.

Complaint GA00161940 was investigated and found not substantiated.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.

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.