Inspection Reports for
Azalea Manor Personal Care Home

The facility failed to complete required monthly fire drills for 2024 and 2025, and failed to provide well-balanced, nutritious meals with sufficient quantity and snacks for 2 of 3 sampled residents. Interviews revealed lack of snack availability and recent staffing changes in the kitchen.

The visit was complaint-related, investigating intake # GA00248993. The complaint was substantiated by findings that the facility failed to document and report a resident's fall and failed to notify responsible parties.

The facility failed to take appropriate actions to address the needs of a resident during a sudden adverse change in condition, including failure to notify the resident's representative and failure to document the incident of a fall for 1 of 3 sampled residents (Resident #1).

The visit was complaint-related, investigating intake #GA00242089. The complaint was substantiated by findings of multiple deficiencies in staff training, certification, personnel documentation, fire safety, and proxy caregiver consent.

The facility failed to ensure that staff had current certification in emergency first aid and cardiopulmonary resuscitation, did not provide required annual training hours, lacked documentation of satisfactory personnel determinations, failed to conduct monthly fire drills since March 2023, and did not maintain required proxy caregiver consent and competency documentation.

The investigation was triggered by complaints regarding Resident #1 who eloped on 10/30/22 and 10/31/22, requiring police intervention and hospital assessment. The resident was discharged to a memory care facility on 11/8/22. The complaint intakes investigated were #GA00229304 and #GA00229376.

The facility failed to admit or retain only residents whose needs are within the home's capabilities and failed to ensure adequate and appropriate care for one sampled resident who eloped twice and required a locked memory care facility, resulting in the resident's discharge to a memory care facility.

The investigation was initiated due to intake #GA00228020 and #GA00228034. Resident #1 was found approximately 0.5 miles from the facility on 9/17/22 by law enforcement and returned to the facility. Resident #1 had eloped on two other occasions without incident reports. The resident has cognitive issues and requires supervision when ambulating.

The facility failed to ensure staff had documented residents' rights training for 3 sampled staff members. Additionally, the facility failed to utilize appropriate effective safety devices to protect a resident at risk of eloping, as evidenced by Resident #1 being found approximately 0.5 miles from the facility and multiple exit doors lacking audible alert devices.

The investigation was based on complaint intakes #GA00203276 and #GA00203329. Staff B verified that his/her signature on the controlled substance log for Resident #2 was forged.

The facility failed to have work performance reviews for unlicensed staff performing specialized tasks such as medication administration, and failed to ensure medication administration records (MAR) were updated each time medication was taken. Additionally, forged signatures were found on controlled substance logs for medication administration.

The visit was complaint-related, investigating intake #GA00202896 and #GA00202917. The investigation found substantiated deficiencies including inadequate staffing, environmental issues, recordkeeping failures, and failure to report a serious injury.

The facility failed to ensure adequate staffing to meet residents' safety and care needs, failed to maintain proper ventilation and temperature in resident rooms, improperly allowed use of space heaters, failed to maintain resident files, and failed to report a serious injury to the Department.

The inspection was conducted to investigate intake #GA00202293.

The facility was found deficient in multiple areas including failure to obtain satisfactory criminal records checks for employees, failure to maintain personnel files, lack of work performance reviews for unlicensed staff, insufficient staff time for resident hygiene assistance, failure to conduct fire drills, improper storage of hazardous materials, excessively hot water temperature, lack of sufficient activities for residents, failure to provide nutritious snacks, presence of expired food items, and failure to maintain a three-day supply of non-perishable food and water for emergencies.

Investigation of intake # GA00201911; visit was complaint-related.

The facility failed to have an effective system to manage medications, including storing medications under lock and key. During a tour, two medication carts were observed unlocked, and staff admitted forgetting to lock them.

This inspection was a follow-up to a previous complaint investigation conducted on 4/08/19.

The facility failed to ensure that 1 of 3 sampled staff (Staff F) had current certification in emergency first aid and cardiopulmonary resuscitation (CPR) within the first sixty days of employment. Staff F completed the required trainings on 10/23/19, the last day of the inspection.

Investigation intake #GA00200107 was conducted due to complaints regarding staff file maintenance and resident care deficiencies. The complaint was substantiated based on findings.

The facility failed to maintain staff files for a departed employee and failed to ensure adequate and appropriate care for 4 of 8 sampled residents, including delayed staff response to calls for assistance, residents' beds soaked with urine, and improper administration of Fentanyl patches.

The visit was complaint-related, investigating three intake numbers. The complaint was substantiated by findings of plumbing issues and medication refill failures.

The facility failed to maintain bathroom plumbing and fixtures in good working order, as evidenced by shower knobs both marked cold in Resident #1's bathroom. Additionally, the facility failed to ensure timely refills of prescribed medications for Resident #2, resulting in interruption of routine dosing.

The visit was triggered by complaint investigations related to intake #GA00195726, #GA00195620, and #GA00195605.

The facility failed to ensure work-related training within the first 60 days for staff, failed to provide and document medication training for unlicensed staff assisting with medication self-administration, failed to update Medication Assistance Records for residents, failed to obtain written informed consent for proxy caregivers for some residents, failed to maintain annual skills competency checklists for proxy caregivers, and failed to use results of the Test of Functional Health Literacy (TOFHLA) for proxy caregivers.

Complaint #GA00189771 was investigated during this visit. The investigation found medication administration record deficiencies and controlled drug discrepancies.

The facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 6 sampled residents (Resident #6). Additionally, a discrepancy was found in the controlled drug record for Resident #3 regarding Alprazolam 0.25 mg tablets.

Complaint #GA00186076 was investigated. The complaint involved concerns about staff training and medication administration.

The facility failed to ensure that at least one staff member with required training was present at all times, failed to provide sufficient staff time to ensure medications were given as prescribed to a resident, failed to provide and document medication training for unlicensed staff assisting with medication self-administration, and failed to update the Medication Assistance Record each time medication was offered or taken.

This was a follow-up visit to a complaint investigation conducted on 6/8/2017 regarding admission of non-ambulatory residents.

The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, as evidenced by Resident #1 who was non-ambulatory and bedridden without any waivers in place.

This follow-up visit was related to complaints #GA00172362 and #GA00172722.

The facility failed to ensure that all employees received required physical examinations and TB screenings prior to employment, retained a resident who required care beyond the facility's permitted level, and failed to properly document medication administration for multiple residents.

The investigation was initiated due to complaints #GA001745172 and #GA00175172 regarding staffing inadequacies and resident care concerns.

The facility failed to maintain adequate staffing levels to meet residents' safety and care needs, admitted non-ambulatory residents without proper waivers, failed to enforce safe food handling practices, did not maintain complete resident health files, and failed to document and respond appropriately to changes in resident conditions.

The inspection included investigation of complaints #GA00172362 and GA00172722.

The facility failed to meet multiple regulatory requirements including workforce health screenings, fire safety inspections, admission criteria for residents, proper documentation of resident files, medication administration, resident rights, and incident reporting. Several deficiencies were noted related to staff qualifications, safety devices, food service permits, and resident care.