Inspection Report Summary
The most recent inspection on January 14, 2025, found no deficiencies during a revisit survey verifying correction of prior issues. Earlier inspections in late 2024 identified several deficiencies related to unsecured medication carts, infection control during wound care, food safety practices, and incomplete background checks for licensed practical nurses, as well as fire safety code violations including smoke detector testing and sprinkler maintenance. No fines, immediate jeopardy findings, or license actions were listed in the available reports. Complaint investigations from 2022 and 2024 were unsubstantiated, and prior COVID-19 reporting deficiencies from 2022 and 2023 were corrected by follow-up surveys. The facility’s recent inspections show improvement with previously cited deficiencies addressed and no new issues noted in the latest surveys.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
73 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Azalealand Nursing Home following a survey completed on January 14, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 73
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard survey concluded on November 7, 2024.
Findings
All deficiencies cited in the prior Standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 74
Capacity: 107
Deficiencies: 0
Date: Dec 2, 2024
Visit Reason
An unannounced Emergency Preparedness survey was conducted following a State Agency Annual Emergency Preparedness Survey to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in substantial compliance with 42 CFR 483.73 for Emergency Preparedness and with Medicare/Medicaid participation requirements related to Life Safety from Fire under 42 CFR Subpart 483.90 and NFPA codes.
Inspection Report
Routine
Census: 70
Deficiencies: 5
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including abuse prevention, nurse competencies, medication storage, food safety, and infection control practices.
Findings
The facility failed to consistently implement background checks for licensed practical nurses, evaluate wound care nurse competencies, secure medication and treatment carts, enforce food safety standards including beard restraints and labeling of resident food, and implement proper infection control practices during wound care, increasing risk of harm to residents.
Deficiencies (5)
Failed to provide evidence of background checks for three Licensed Practical Nurses (LPNs).
Failed to evaluate the Wound Care Registered Nurse's competencies and noted infection control concerns during wound care.
Failed to ensure two of five treatment and medication carts were locked and secured when unattended.
Failed to ensure staff wore beard restraints when serving food and failed to ensure resident food items stored in a nourishment refrigerator were labeled and dated.
Failed to implement enhanced barrier precautions and proper infection control practices during wound care for one resident.
Report Facts
Residents present: 70
Licensed Practical Nurses without background checks: 3
Treatment and medication carts unlocked: 2
Wounds treated during observation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Named in background check deficiency |
| LPN 9 | Licensed Practical Nurse | Named in background check deficiency |
| LPN 10 | Licensed Practical Nurse | Named in background check deficiency and medication cart interview |
| Wound Care RN | Registered Nurse | Named in wound care competency and infection control deficiency |
| Human Resources Director | Interviewed regarding background check policies | |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care competency and infection control |
| Administrator | Facility Administrator | Interviewed regarding background checks, medication cart security, and wound care expectations |
| Food Service Director | Food Service Director | Interviewed regarding beard restraint policy |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding medication cart security |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding medication cart security |
| RN 1 | Registered Nurse | Interviewed regarding treatment cart security |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding treatment cart security |
| Dietary Manager | Dietary Manager | Interviewed regarding nourishment refrigerator labeling |
| CNA 6 | Certified Nursing Assistant | Interviewed regarding nourishment refrigerator restocking |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding nourishment refrigerator use |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding infection control and EBP |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
A State Licensure survey was conducted at Azalealand Nursing Home from November 4, 2024, through November 7, 2024, to assess compliance with state health regulations and facility policies.
Findings
The inspection revealed multiple deficiencies including unsecured medication and treatment carts, failure to implement enhanced barrier precautions during wound care, improper food safety practices including unlabeled and undated food items, failure to wear beard restraints in dietary services, and incomplete background screening documentation for licensed practical nurses.
Deficiencies (4)
Two of five treatment and medication carts were unlocked and unsecured when unattended by staff, risking unauthorized access to medications.
Failure to implement enhanced barrier precautions and proper infection control during wound care for one resident, increasing risk of infection and cross-contamination.
Staff failed to wear beard restraints when serving food, and resident food items in nourishment refrigerator were not labeled or dated.
Facility failed to provide evidence of background checks for three licensed practical nurses, risking resident safety.
Report Facts
Census: 70
Treatment and medication carts unlocked: 2
Licensed Practical Nurses without background checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication cart security and wound care expectations |
| Food Service Director | Food Service Director (FSD) | Observed not wearing beard restraint and discussed facility policy on beard restraints |
| Administrator | Facility Administrator | Provided statements on medication cart locking expectations and background check policies |
| Human Resources Director | Human Resources (HR) Director | Discussed background check procedures and policy changes |
| Wound Care Registered Nurse | Wound Care RN | Observed failing to follow proper infection control and enhanced barrier precautions during wound care |
Inspection Report
Routine
Census: 70
Deficiencies: 5
Date: Nov 7, 2024
Visit Reason
A standard survey was conducted by Certiserv LLC on behalf of the State of Georgia Department of Community Health at Azalealand Nursing Home from November 4 through November 7, 2024, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to conduct required background checks for licensed nurses, inadequate wound care infection control practices, unsecured medication carts, failure to use beard restraints in food service, unlabeled and undated resident food items, and failure to implement enhanced barrier precautions during wound care.
Deficiencies (5)
Failed to provide evidence of background checks for three Licensed Practical Nurses prior to employment.
Failed to evaluate the Wound Care RN's competencies and noted infection control concerns during wound care.
Failed to ensure two of five treatment and medication carts were locked and secured when unattended.
Failed to ensure staff wore beard restraints when serving food and failed to ensure resident food items in nourishment refrigerator were labeled and dated.
Failed to implement enhanced barrier precautions and proper infection control during wound care for a resident with open wounds.
Report Facts
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Named in deficiency for lack of background check. |
| LPN 9 | Licensed Practical Nurse | Named in deficiency for lack of background check. |
| LPN 10 | Licensed Practical Nurse | Named in deficiency for lack of background check and interviewed about medication cart security. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound care competency, medication cart security, and infection control practices. |
| Wound Care Registered Nurse | Wound Care RN | Observed providing wound care with infection control deficiencies. |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding beard restraint policy and food safety. |
| Administrator | Facility Administrator | Interviewed regarding background checks, medication cart security, and food safety policies. |
| Licensed Practical Nurse 11 | Licensed Practical Nurse | Interviewed about medication cart security. |
Inspection Report
Life Safety
Census: 73
Capacity: 107
Deficiencies: 3
Date: Nov 5, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to perform required smoke detector sensitivity testing, fire sprinkler heads obstructed or dusty, and improper materials used to seal penetrations in fire walls and smoke compartments.
Deficiencies (3)
Failure to ensure required smoke detector sensitivity testing was performed.
Failure to ensure fire sprinkler heads were clear from dust and obstructions.
Failure to ensure proper material was used to seal penetrations in fire walls and smoke compartments.
Report Facts
Census: 73
Total Capacity: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00232449 and GA00240903.
Complaint Details
Complaints GA00232449 and GA00240903 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints GA00232449 and GA00240903 were unsubstantiated with no deficiencies cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN between 06/05/2023 and 06/11/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 15, 2023
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 05/08/2023 and 05/14/2023 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The inspection was conducted as an annual survey of Azalealand Nursing Home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from November 15, 2022 through November 17, 2022 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from November 15, 2022 through November 17, 2022.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
A standard survey was conducted at Azalealand Nursing Home from November 15, 2022 through November 17, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 82
Capacity: 107
Deficiencies: 4
Date: Nov 15, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to ensure the fire alarm breaker was red and locked, lack of proper maintenance and inspection of the sprinkler system, unsecured open spaces in electrical panels, and improper use of extension cords and multi-plug adapters.
Deficiencies (4)
Fire alarm breaker was not red nor locked in the ON position.
Wet sprinkler system 5-year inspection not done and pressure gauges are out of date.
Open spaces in electrical panels and missing junction box covers.
Extension cords used as permanent wiring and multi-plug adapters in use in nurse's stations and offices.
Report Facts
Census: 82
Total Capacity: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 7, 2022
Visit Reason
The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/31/2022 and 11/06/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00222333.
Complaint Details
Complaint #GA00222333 was substantiated with no regulatory violations.
Findings
The complaint #GA00222333 was substantiated but no regulatory violations were found.
Inspection Report
Routine
Census: 59
Deficiencies: 0
Date: Nov 20, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 66
Deficiencies: 0
Date: Oct 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
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 CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 66
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 21, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 8/4/2020 COVID-19 Infection Control Survey.
Findings
All deficiencies cited as a result of the 8/4/2020 COVID-19 Infection Control Survey were found to be corrected.
Report Facts
Previous survey date: Aug 4, 2020
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 1
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with infection control regulations due to failure to ensure staff followed transmission-based precautions for a COVID-19 positive resident, specifically improper handling of a contaminated drinking cup by a Certified Nurse Aide.
Deficiencies (1)
Failure to ensure staff followed infection control policies related to transmission-based precautions for a COVID-19 positive resident, including improper handling of contaminated drinking cup.
Report Facts
Total census: 71
Date of positive COVID-19 test: Jul 27, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nurse Aide | Named in infection control deficiency for improper handling of contaminated drinking cup |
| Infection Control Nurse | Provided interview confirming transmission-based precautions and contamination incident |
Inspection Report
Abbreviated Survey
Census: 72
Deficiencies: 0
Date: Jun 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on June 2, 2020 to assess compliance with emergency preparedness and infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, having implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 72
Inspection Report
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Azalealand Nursing Home following a regulatory survey completed on March 5, 2020.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or findings are detailed on this page.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2020-01-09.
Findings
All deficiencies cited as a result of the 2020-01-09 standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 24, 2020
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 survey tags have been corrected during the follow-up survey.
Inspection Report
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
The inspection was conducted to review compliance with medication orders upon admission, specifically to verify that the facility ensured the medication levothyroxine was ordered for a resident upon admission.
Findings
The facility failed to ensure that levothyroxine was ordered upon admission for one resident (#70) out of 34 sampled residents. The resident's hospital discharge orders included levothyroxine 100 mcg daily, but the facility's physician orders did not reflect this on admission, resulting in delayed medication administration and elevated TSH levels. Interviews with nursing staff confirmed the order was overlooked during transcription.
Deficiencies (1)
Failed to provide doctor's orders for the resident's immediate care at the time the resident was admitted, specifically the medication levothyroxine.
Report Facts
Residents sampled: 34
TSH blood level: 9.38
TSH blood level: 12.24
Medication dose: 100
Medication dose: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Assistant Director of Nursing (ADON) | Interviewed regarding transcription of medication orders and admission process | |
| Director of Nursing (DON) | Interviewed regarding admission orders transcription and verification process |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The inspection was conducted as a Licensure Survey for Azalealand Nursing Home.
Findings
No deficiencies were identified during the Licensure Survey.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
A standard survey was conducted from January 6, 2020 through January 9, 2020, including investigation of Complaint Intake Number GA00201125.
Complaint Details
Complaint Intake Number GA00201125 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to ensure a medication order for levothyroxine was correctly transcribed upon admission for one resident (#70).
Deficiencies (1)
Failure to ensure the medication levothyroxine was ordered upon admission for one resident (#70).
Report Facts
Resident census: 68
Sampled residents: 34
TSH level: 9.38
TSH level: 12.24
Medication dosage: 100
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN EE | Registered Nurse | Verified admission orders originally put in by DON |
| Assistant Director of Nursing | Interviewed regarding order transcription process | |
| Director of Nursing | Interviewed regarding order transcription and admission orders |
Inspection Report
Life Safety
Census: 68
Capacity: 107
Deficiencies: 2
Date: Jan 7, 2020
Visit Reason
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.
Findings
The facility was found not in substantial compliance due to failure to maintain smoke compartment doors that close completely and failure to segregate empty oxygen cylinders from full cylinders, placing residents at risk in the event of fire.
Deficiencies (2)
Failed to maintain a smoke compartment door that closed completely as required by NFPA 101, 2012 Edition, Chapter 19.
Failed to separate oxygen cylinders so that empty cylinders were segregated from full cylinders as required by NFPA 99.
Report Facts
Residents at risk due to smoke door deficiency: 50
Residents at risk due to oxygen cylinder storage deficiency: 6
Census: 68
Total licensed beds: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to smoke compartment door and oxygen cylinder storage during facility tour. |
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 0
Date: Jun 26, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00195559 at Azalealand Nursing Center.
Complaint Details
Investigation of complaint GA00195559; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from August 6, 2018 through August 9, 2018.
Findings
All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 72
Capacity: 107
Deficiencies: 0
Date: Aug 6, 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
Follow-Up
Deficiencies: 0
Date: Nov 2, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey found that all previously cited deficiencies had been corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Landolt | Conducted the follow-up survey |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 0
Date: Sep 21, 2017
Visit Reason
A standard survey was conducted at Azalealand Nursing Home from September 18, 2017 through September 21, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 69
Capacity: 107
Deficiencies: 1
Date: Sep 19, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to failure to maintain proper access to an electrical panel in the Physical Therapy closet, where walkers were stacked in front of the breaker panel, posing a fire hazard risk to residents and staff.
Deficiencies (1)
Failure to maintain proper access to an electrical panel in the Physical Therapy closet due to walkers being stacked in front of the breaker panel.
Report Facts
Residents and staff at risk: 10
Census: 69
Certified Beds: 107
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