The most recent inspection on May 22, 2025, identified a deficiency related to incomplete fire drills, which were not conducted quarterly on each shift or with the local fire department every six months as required. Earlier inspections showed a mix of findings, including issues with dishwashing temperatures and freezer maintenance in May 2024, as well as training and medication administration deficiencies in January 2023. Complaint investigations during this period were mostly unsubstantiated, except for one substantiated complaint in February 2024 that did not result in cited deficiencies. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The pattern suggests some ongoing operational issues, particularly with safety drills and equipment maintenance, but recent complaint investigations have not revealed additional deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
This visit was for a State Residential Licensure Survey conducted on May 22, 2025.
Findings
The facility failed to ensure fire drills were completed quarterly on each shift or in conjunction with the local fire department every 6 months for the 12 months reviewed. Fire drills were only conducted on the day shift, which could potentially affect all 55 residents.
Deficiencies (1)
Description
Failed to ensure fire drills were completed quarterly on each shift or in conjunction with the local fire department every 6 months for 12 months reviewed.
Report Facts
Residents affected: 55Fire drills conducted: 7
Employees Mentioned
Name
Title
Context
Melissa Prenatt
Administrator
Signed the report
Executive Director
Interviewed regarding fire drill compliance
Maintenance Assistant
Interviewed regarding fire drill scheduling and budget
Maintenance Director
Interviewed regarding fire drill scheduling and compliance
This visit was conducted for the investigation of Complaint IN00439104.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00439104 was investigated and found to have no deficiencies related to the allegation.
This visit was for a State Residential Licensure Survey that included the investigation of Complaint IN00433178.
Findings
The facility failed to ensure the dishwashing equipment reached appropriate temperatures to disinfect dishes and the walk-in freezer was free from ice build-up, potentially affecting all 44 residents who consumed meals at the facility. Immediate corrective actions were taken, including increasing the water heater temperature and insulating freezer pipes.
Complaint Details
Complaint IN00433178 was investigated and state deficiencies related to the allegations were cited at R0154.
Deficiencies (2)
Description
Dishwashing equipment did not reach the required temperature to disinfect dishes during multiple observations.
Walk-in freezer had ice build-up with icicles and water dripping onto food items.
Report Facts
Dishwasher temperature readings: 116Dishwasher temperature readings: 119Icicle length: 10Residential census: 44
Employees Mentioned
Name
Title
Context
Melissa Prenatt
Laboratory Director or Provider/Supplier Representative
Signed the report.
Dietary Manager
Indicated dishwasher cycle should be between 120 and 125 degrees F and reported not noticing ice build-up in freezer.
Maintenance Director
Ran dishwasher during observations and reported contacting dishwasher maintenance company.
Dietary Aide 5
Indicated dishwasher temperature was usually 116 degrees F on the gauge.
Executive Director
Reported dishwasher company repaired dishwasher on 5/3/24 due to temperature issues.
This visit was conducted for the investigation of Complaint IN00426740.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00426740 - Substantiated - No deficiencies related to the allegations are cited.
This visit was conducted for the investigation of Complaint IN00423641.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00423641 was investigated and found to have no deficiencies related to the allegations.
This visit was conducted for the investigation of Complaint IN00420153.
Findings
No deficiencies related to the allegations in Complaint IN00420153 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00420153 was investigated and found to have no deficiencies related to the allegations.
This visit was for the Investigation of Complaint IN00411220.
Findings
No deficiencies related to the allegations are cited. Azalea Hills was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00411220.
Complaint Details
Complaint IN00411220 - No deficiencies related to the allegations are cited.
This visit was for a State Residential Licensure Survey to assess compliance with state regulations for the facility.
Findings
The facility was found noncompliant in ensuring required in-service training for personnel, including dementia training, abuse prevention, and resident rights. Additionally, medication administration practices were deficient, with medications pre-packed by facility nurses contrary to policy, affecting 19 of 42 residents.
Deficiencies (2)
Description
Failure to ensure employees completed required dementia training, abuse inservicing, and resident rights training.
Preparation of doses for more than one scheduled administration is not permitted; facility nurses pre-packed medications for multiple residents.
Report Facts
Personnel files reviewed: 5Residents receiving medication administration services: 42Residents affected by medication administration deficiency: 19In-service training hours required: 8In-service training hours required: 4Dementia training hours required: 6Dementia training hours required annually: 3
Employees Mentioned
Name
Title
Context
Cassandra McCoun
Laboratory Director or Provider/Supplier Representative
Signed the report
LPN 8
Licensed Practical Nurse
Observed administering medications and described medication planner setup
Director of Nursing
Director of Nursing
Provided information about medication administration practices and facility policies
QMA 8
Qualified Medication Aide
Described medication administration process
LPN 10
Licensed Practical Nurse
Observed medication planners and medication administration
LPN 11
Licensed Practical Nurse
Responsible for filling medication planners weekly
Executive Director
Executive Director
Interviewed regarding missing training documentation and medication policies
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